‘It’s time to step up’: Epidemiologist Isaac Bogoch on Ontario’s vaccine rollout

TVO.org speaks with the infectious-diseases doctor about second-dose timing, the role of primary care — and why we might not be facing a one-dose summer
By Nathaniel Basen - Published on May 17, 2021
Isaac Bogoch is a member of the province’s vaccine task force. (Courtesy of Isaac Bogoch)

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Ontario administered 112,330 doses of COVID-19 vaccine on May 16, a new record for a Sunday. New daily case counts are also falling in most of the province, especially in Toronto and Peel Region, as the vaccine supply ramps up.

TVO.org speaks with Isaac Bogoch — epidemiologist, infectious-diseases doctor, and member of the province’s vaccine task force — about the next phase of Ontario’s vaccine rollout, strategy shifts, and why it might not be a one-dose summer.

TVO.org: Let’s start with the good news. On Sunday, Ontario vaccinated a record number of people for a Sunday, and it is now opening up bookings to people 18 years and older. This feels like a turning point in the vaccination program. How did we get here?

Isaac Bogoch: It is a huge turning point for the vaccine program. Essentially, it’s open season now for vaccinations across the province. You can only do that when you have large and steady supply of vaccines rolling in. This is largely driven by Pfizer and secondarily driven by Moderna, but we just have large and regular shipments of Pfizer coming in. That means Ontario gets more, and we can put those into the 34 public-health units across the province. They’ve all really scaled up their ability to launch mass-vaccine clinics; some have pop-up clinics and mobile clinics. We know that pharmacies are ramping up as well. Primary care is, too — unfortunately too slow for my liking, but still slowly ramping up capacity. And, with greater product, you can certainly lower the age cutoff.

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I think it’s also simple: There’s no changing policy. There are no moving targets. It’s basically anyone 18 and up can get a vaccine starting on Tuesday.

TVO.org: People have at times criticized the province for not having introduced an effective central booking system, and there’s certainly merit to that. But the pop-up and mobile clinics seem to be working well. What are the trade-offs there, and what makes these mobile clinics so effective?

Bogoch: I totally agree that the centralized signup system is convoluted. You’ve had innovation from the general public to help circumvent this — you have Vaccine Hunters and another individual who made a phone number you can text that will identify clinics nearby. I’m not a vaccine snob: whatever does the job is the right move. So, yeah, I think that the centralized booking system was problematic. Some public-health units just had their own booking system as well, and many people didn’t use the centralized system. That worked well in some in some public-health units.

From an equity standpoint, if we look in early April, for example, there was certainly inequity in the vaccines allocated — especially where we saw proportionately more people outside of heavily impacted areas vaccinated compared to those living in those disproportionately impacted areas. We know that there are several postal codes that have borne the brunt of this pandemic from the very beginning — not just from the virus, but also from policies that we use to curb virus spread. So, it was really fantastic to see these mobile units and these pop-up units work and spring up in these hot-spot areas. For a period of time in late April, they received 25 per cent of the provincial vaccine allotment. And then, of course, the first two weeks of May, they received 50 per cent of the provincial allotment.

And that basically lowers barriers to vaccination, right? You bring the vaccine to the people, not people to the vaccine. And we saw some very, very successful pop-ups and mobile clinics in community centres and houses of worship. Some places were going door to door in high-density urban residential areas.

The data is the data, right? If you look at where we are right now, we have proportionately more people in those hot-spot neighborhoods vaccinated compared to non-hot-spot neighbourhoods. The job isn’t done — no one can say mission accomplished — but it’s working well.

As we’re moving toward a per capita allotment of vaccines throughout the province, it doesn’t mean that equity suddenly stops — you still should have these pop-up clinics, these mobile clinics, and these programs to really lower barriers to vaccination. On the other hand, there are a lot of people that don’t live in those hotspot areas that need to be vaccinated. There are a lot of essential workers and people with underlying medical conditions, for example, that need access to the vaccines. With greater numbers of vaccines coming into the country, that also means greater number of vaccines to Ontario, which means greater number of vaccines throughout the entire province — and that also includes hot-spot areas. So I think I think we’ll be okay.

TVO.org: Speaking of that, with the number of doses coming in, Ontario should be set for a huge week in vaccinations. What can we expect to see?

Bogoch: We’re getting massive shipments. When we look at the last couple of weeks, there were some big days; we crossed that 150,000 doses per day mark one day last week. What’s interesting is that the non-hot-spot public-health units — so, about 30 of the 34 — will be getting way more vaccines than what they received in the past. It’s time to step up: let’s see what you got. They’ve really got to start to deliver this in their mass-vaccine clinics.

What’s really helpful is that pharmacies were administering AstraZeneca and did a remarkable job. Especially when we saw that age cutoff go from 50 to 45, the pharmacists and the pharmacies stepped up and were able to administer tens of thousands of doses per day. Now we’re moving the mRNA vaccines into pharmacies as well. We’re at about 500 [pharmacies], and the goal is to get to about 2,400. As you have more nodes throughout the province administering vaccines — be it a pharmacy, a mass-vaccine clinic, a primary-care site — we’ll just be able to get those numbers up faster.

The other thing to work on and to really focus on is primary care. That means family doctors and nurse practitioners. Sadly, they’ve been underutilized, and that’s a shame. because they’re so good. There’s trust, there’s counselling, there are lower barriers to vaccines: there’s just a lot that goes into primary care, either a family doctor or nurse practitioner, administering a vaccine in their clinic. It’s being done in about 300 centres throughout Ontario now, but it’s going to massively expand as well.

I’m a little disappointed that it has taken this long to expand, but it is going to, and they’re going to be administering Moderna in their clinics with increasing frequency. That’s not just going to help with the numbers. It’s also going to help populations out that may not go to a pharmacy or may not go to a mass-vaccine site. There’s just a lot of good that comes with primary-care vaccinating, so I look forward to seeing that expand quickly.

TVO.org: There was a pre-print released last week that seemed to support the National Advisory Council on Immunization’s at times controversial recommendations on extended dose intervals. What do we know about that right now?

Bogoch: It’s interesting. Canada spacing out the doses by up to four months — I think to be fair and honest about this, that the reason that was done is because, one, it’s likely okay to separate those doses, because that’s what we do with other vaccines. We know that that’s a reasonable thing to do. Second, we didn’t actually have the supply to stick with the dosing regimen that was done in the clinical trials: day 21 and day 28. It’s a combination of those, but I would imagine that if we had unlimited supply, we probably would have just stuck with [the manufacturer’s] dosing regimen.

Having said that, when you look at other vaccines and other infectious diseases, it’s been well-known, long before COVID-19, that you do mount a more robust immune response with some of these dosing delays. You look at Hepatitis A and Hepatitis B vaccines, you can look at a lot of different multi-dose vaccine, and you just get a better immune response if you delay that second dose. And the data from the United Kingdom, at least in that pre-print, demonstrated that people would have about a three-and-a-half-times greater antibody response if the second dose was given at three months compared to about three weeks. That makes sense. It doesn’t really come as a huge surprise to people who are immunologists or who follow infectious diseases closely.

I think it’s also fair to say that you don’t need a one-size-fits-all answer here. There are people, for example, on the older end of the spectrum, or people with underlying medical conditions, who might not be able to mount a significant immune response after the first dose. I think it’s reasonable to shorten that to keep it to somewhere between two to three months or so, instead of up to four months. We should really be working on getting second doses in those folks.

TVO.org: And do you think that is going to happen? Is there going to be a policy change for people, say, 80 and older?

Bogoch: I don’t know. I’m not sure. We certainly have a policy for underlying medical conditions. So, for example, in Ontario, people who have certain types of cancers, people who have organ transplants, people on dialysis — there’s pretty decent data demonstrating that they don’t mount a very significant response, or as significant a response, to a first dose of the vaccine. And the second dose of the vaccine has been moved up. We haven’t done it for those over the age of 80. I would be happy with that. I think that would be reasonable, but we haven’t done that.

I think it’s fair to say that we should be working on getting second doses into people before their four months. If I was to prioritize, I would certainly prioritize based on age and based on underlying medical conditions.

TVO.org: Yeah, this has been called a one-dose summer, but, looking at the numbers, it seems to me that that shouldn’t actually be the case for a large number of Ontarians. People should be able to get their second doses before the end of the summer. Is that right? How should the next few months look?

Bogoch: I think it’s going to be a one-and-a-half-dose summer. A lot of people are going to get a second dose throughout the summer, and I think it’d be very helpful to have guidance on what is acceptable behaviour for individuals who’ve had two doses of a vaccine — two weeks after the second dose — because there’s going to be a growing number of people who are going to fall into that category.

I think the U.S. did a really good job with that — they gave some very practical guidance to navigate this sort of bizarre interim period where some of us are fully vaccinated. Things like, fully vaccinated people can get together in someone’s house in an indoor space without having to mask or physically distance, because everyone’s vaccinated. Or, if the grandkids aren’t vaccinated but are low-risk and have no symptoms, vaccinated grandparents can hug their grandkids. I think that was very pragmatic advice, and I wonder if we’re going to see some of that from the federal government or provincial governments. I hope we do.

TVO.org: As an outsider, it seems throughout this pandemic, you’ve had sort of two roles when it comes to the vaccine rollout. The first is helping guide the rollout, offering insight and guidance and practical help. The second is that, through social media and traditional media, you’ve been helping to inform the public about the rollout. At times, that’s meant letting people know that some of the loudest and gloomiest scenarios predicted in the vaccine rollout would not come to pass or would be fixed. What have you learned doing that sort of work? Or is that an unfair read of the situation?

Bogoch: Your first part is spot on: There’s a ton of meetings. There’s a lot of discussion about how science should guide policy, how equity should guide policy — and that’s consumed a ton of time.

And then, of course, yeah, it’s very interesting with part two of that question. Certainly, I fully appreciate that politics and public health intersect. And that intersection isn’t the most exciting thing for me, but you can’t ignore it. And I really, truly believe there are very fair and reasonable criticisms or critiques of the vaccine program.

I also think it’s very fair to say that some things have actually gone rather well. And when you watch some of these critiques of the vaccine rollout — again, everyone’s entitled to their opinion, and people will say what they say — I just prefer that it’s honest. Sometimes you see, for example, I would say just inaccurate or unfair critiques. Again, people can have whatever opinion they want. That’s cool. I see very valid ones as well. But sometimes you see people magnify, you know, a two-out-of-10 problem into a 10-out-of-10 problem. And you also see the opposite: some people take a bigger problem and sort of sweep it under the rug.

It’s not my job, or at least, it’s not my official job, to be the spokesperson or the communicator. But in all fairness, I speak with the media pretty regularly, so I just end up fielding those questions. I try to keep it as fair and honest as possible. There are things that are going well — great, we can talk about it. There are things that aren’t going well — great, we should talk about it and work to improve it. And that’s basically it.

I try to be as open and transparent as possible. Remember, I’m not the government, and even if I were, I would critique what’s going well and what’s not going well. I try to be as honest about it as possible. Even in our conversation over the last few minutes, I think there are obvious things that are going well, like the numbers are going up, the equity has been addressed. We’re not done, but I think there’s been a really impressive push to create vaccine equity. I think critiques would be, there’s a very convoluted sign-up system, and primary care has not been mobilized as quickly as we could have. I think those are two of the biggies.

But there have been some excellent successes. As you point out, there are these mass-vaccine clinics, these pop-up clinics, that are getting the right needles into the right arm and in the right place at the right time — and by the thousands. This is awesome.

When you look at the pace of vaccination, we’re vaccinating about 139,000 to 142,000 people per day — that’s close to 1 per cent of our population in Ontario per day. That’s as fast as anywhere else on the planet, and it’s comparable to when the U.K., Israel, and the U.S. were firing on all cylinders vaccinating quickly. Those are impressive days.

And I fully appreciate that it’s no time to be complacent; it’s no time to pat ourselves on the back and sit out. But it’s still impressive. We can still push further and push for greater speed, better equity, smoother programs: we still can and should do that. But we also have to recognize that when we’re hovering around 140,000 vaccines per day, we’re doing something really good.

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


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