‘Implementation is key’: Epidemiologist Isaac Bogoch on Ontario’s new testing plan

TVO.org asks the infectious-disease expert about rising cases, vaccines for kids — and whether symptomatic testing at pharmacies is a good idea
By Nathaniel Basen - Published on Nov 18, 2021
Isaac Bogoch is an associate professor at the University of Toronto. (Courtesy of Isaac Bogoch)

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COVID-19 cases are on the rise again in Ontario, and the province has released a testing plan for the fall and winter: it’ll be mounting pop-up testing “blitzes” in high-traffic places, distributing PCR self-tests to Ontario schools, and sending students home for the holidays with rapid-antigen tests to help prevent spread in the new year.

The government will also be pursuing another novel approach. “In the coming days,” officials said Thursday, pharmacies will begin offering testing for symptomatic people. The province says that participating stores “will be required to implement and follow robust infection prevention and control measures,” but the move has met with criticism from some health professionals and pharmacy staff.

TVO.org speaks with epidemiologist Isaac Bogoch about the plan’s risks and benefits — and what the next few months could look like.  

TVO.org: Let’s start with the bad: cases are rising in Ontario, especially in places like Algoma and Kingston. What’s happening?

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Isaac Bogoch: So, basically, to no one’s surprise, under-vaccinated populations are having difficulty right now. You've got a very contagious Delta variant, and it's going to spread in under-vaccinated populations. Especially now that it's fall, and we've got more and more people spending more time in indoor settings, we're giving this virus a lot more opportunities to be transmitted. And that's exactly what we're seeing. 

So I think throughout the fall and winter, sadly, we're going to see under-vaccinated communities disproportionately impacted with outbreaks. There is a way around this: we can still work on promoting vaccination and lowering barriers to vaccination in those communities. It will help, just like it helps other everywhere else in the world. We have just got to keep pushing forward in those areas.

TVO.org: Now for the good: pediatric vaccines are coming very shortly; reportedly, we’ll be getting doses in little arms this month. At the same time, Kieran Moore, Ontario's chief medical officer of health, has said it will likely be an eight-week dosing interval, meaning that kids won’t be fully vaccinated for the holidays. What’s the rationale for that, and what will one dose do for the holiday season?

Bogoch: It's very exciting that we'll be imminently rolling out vaccination to the five- to 11 year-old cohort in Canada and, of course, in Ontario. I think there's going to be a lot of good that comes of this. Obviously, we know kids can get this infection. We know they can transmit this infection. We know they can amplify this infection in certain settings if proper steps aren't taken. This vaccine will really help protect kids from getting the infection and also protect their close contacts, including classmates, including parents or grandparents or other vulnerable individuals around them. So I think we'll see a lot of good come from the pediatric vaccine rollout. 

Now, we heard Dr. Moore discuss that the dosing interval will be about eight weeks or so: that makes sense. I mean, everything we know about multi-dose vaccines, and, of course, everything we've learned about COVID-19 vaccines over the past year, demonstrates that you just produce a more robust immune response if you separate the doses by a couple of months. The other important thing is, we can't ignore the risk of myocarditis, which is inflammation of the heart. And we know that there's a low but still real risk. Even though it's a low risk, it's still there, and we obviously can't ignore it. We've got to be transparent with parents and with families about myocarditis. 

Everything that we've seen, at least from a global standpoint, is that the risk of this goes down if the doses are separated by two to three months. For example, in the United Kingdom, they were giving a single-dose vaccine to the teenage cohort because they were concerned about the risk of myocarditis. Based on emerging data from several parts of the world, they basically said that they're going to start giving the second dose at about the 12-week mark, because the incidence of myocarditis is lower with that. I think that we're going to learn from the same data that others around the world are learning from, and it sounds like the policy in Canada will align with separating those doses longer than what companies suggest in the first place. And that's obviously a good thing.

TVO.org: The other vaccine news is that third doses are becoming available to more and more Ontarians — and the data shows they have a huge protective effect. What do you make of Ontario’s third-dose strategy? And, understanding that nothing is perfect and we’re still learning, what level of confidence can someone have after getting that third dose?

Bogoch: I think it's pretty clear that, for most adults, based on what we know now, this is likely to be a three-dose vaccine. Most people have had the first two doses in a three-dose series. I think it's very possible for Ontario, and of course elsewhere in Canada, to provide their doses in a reasonable and safe manner while still aligning with the World Health Organization's request for a moratorium on a widespread third-dose program. It's fair to say that Ontario could certainly expand its third-dose eligibility, and I'd like to see it expanded to include community-dwelling populations that are 50 years of age and older. You can do that and still align with the World Health Organization. I think we will see a gradual expansion of third-dose eligibility in Ontario. I hope it happens sooner rather than later, but we will very likely see that. 

The other important thing, too, is it's still important to remember that the effectiveness of two doses against severe infection like hospitalization and death is very high. Third doses help improve the effectiveness against getting the infection in the first place, and, of course, we don't want anyone to get this infection. But you don't need a crystal ball to look six months, nine months, a year, two years in the future — we'll probably start a conversation at some point in the future about breakthrough infections following a third dose. We don't know how long a third dose is going to last in terms of effectiveness. I'm totally speculating here, but my guess is that adults will end up getting a third dose at some point in late 2021, early 2022, and then we'll be good for a while. And by a while, I mean probably a few years or so. But who knows.

TVO.org: The other half of that equation is anti-virals, which are being tested and seem promising. How do these work, and what will they do for us?

Bogoch: Oh, yes! It's really exciting. There are two tablets that we're talking about: one is made by Pfizer, and the other is made by Merck. The one by Pfizer reportedly reduces the risk of severe infection by close to 90 per cent; the one by Merck reportedly reduces the risk of severe infection by about 50 per cent. They both take different pathways to prevent the virus from replicating within the human host, so they have different mechanisms of action, but the end result is the virus will stop replicating within us. That's why you actually have to start taking them very soon after infection for someone to reap the benefits of these medications, because when you think about why people get sick from COVID-19, it's not solely the virus replicating in the human — it's also the human’s response and this profound inflammatory response to the virus. And that's why you've got some people, for example, who might be exposed to the exact same virus who have completely different clinical reactions to it.

These anti-virals — for starters, we have a lot of press releases, but we don't actually have a lot of data at our fingertips. But if these antivirals work as well as the companies say, we can put them to good use. Let’s get this out of the way: it's always better to prevent an infection than it is to treat an infection. These are not a substitute for vaccination by any means. Having said that, COVID is going to be around for a while. Sadly, some people are still going to get sick with this virus, and it's absolutely wonderful to have drugs that can help prevent severe infection, hospitalization, and death. 

Now, the key thing here is, everything we've heard about these medications is that they've got to be used quickly in order to for us to realize their true potential. That means you need to have access to diagnostic testing — good, quick access to diagnostic testing with a rapid turnaround time. Then, of course, you need access to these medications. But if we have the right medicine, and if they work as well as the companies say they work, yes, we can certainly put them to good use and really do a lot to keep people out of hospitals. 

I like these because, number one, they're pills, and we don't have a lot of pills for COVID-19. Number two, it's really tailored to outpatient settings, and most therapeutics we have are really tailored to hospital-based setting. So this is really a significant finding and will go a long way to keep people and, of course, health-care systems, protected.

TVO.org: You spoke about access to testing. The province teased earlier this week what it announced in full today: as part of its new policy, symptomatic people can get tested at participating pharmacies. My first reaction to this was that it seemed it would be sensible if done well, but a lot of very smart people had the opposite reaction — and I understand why. Basically: How wrong am I?

Bogoch: It's always, always, good to hear that we will have lower barriers to testing. That is fantastic. If we can lower the barriers for someone who has symptoms suggestive of COVID-19 to get a test to rule in or rule out infection, we're doing something right. So that's stating the obvious. 

Now, when we hear about this diagnostic testing happening in pharmacies, there are a lot of right ways to do this, and there are also a lot of wrong ways to do this. You don't want to put non-infected people at risk of getting this infection. So how would you implement this? Implementation is key. You could, for example, set up a little tent outside, and we know that's about as safe as it gets. So that's one approach. Two years into this pandemic, we also know how to create safer indoor spaces. You could easily have a special entrance for individuals with symptoms; you could separate them from the rest of the store; you can have good ventilation, wear the appropriate PPE, and really not put anyone else at risk of getting this infection. That's another approach. A third approach is obviously to provide a home-testing kit that you could return to the store so you don't put anyone else at risk. There are a lot of right ways to do this. 

Of course, there are some wrong ways of doing this as well. You wouldn't want someone who's got rip-roaring COVID taking their mask off in close proximity to other people who are shopping so that they can get a diagnostic test done. That's obviously the wrong approach. So implementation is key. This can be done safely. The key thing here is, will it?

TVO.org: Finally, what else did you see in the province’s new testing plan that you found interesting, good, or bad? 

Bogoch: You've got the province giving 11 million rapid tests to students — every student gets five rapid tests to use throughout the course of the winter break. I think that's a great idea. I mean, some families will put that to good use; some might not. But, really, I like it because it's actionable. If you have a positive rapid test, you can obviously make the choice to stay home or to confirm that with another test. It's a really helpful intervention to create a much safer return to school in January. The other thing I like, too, is that all these schools are going to have PCR testing — take-home PCR testing — for symptomatic infection. Yet again, lowering the barriers to diagnostic testing is always a good thing. I mean, if students with symptoms have fewer hurdles to overcome to rule in or rule out an infection, that's how you create a safer school. That's how you create a safer home. That's how you create a safer community. This is clearly a smart approach.

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

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