Ontario’s COVID-19 situation is the worst it has ever been, with cases and deaths both hitting record numbers due to a post-holiday spike. The province has passed 5,000 deaths, and the past week has seen several days with more than 4,000 cases. The province is in lockdown, and more restrictions are expected to be announced Tuesday.
Amid all the grim news, there has been one bright spot: the arrival of vaccines. But there have been questions about whether Ontario has enough doses and whether it’s using the ones it has effectively.
TVO.org speaks with University of Ottawa epidemiologist and global health researcher Raywat Deonandan about vaccine strategy, how the next months might go, and when we will finally be able to hug our friends.
TVO.org: I last spoke with you just before the holidays, and we talked a little bit about how you thought they might go. Was it roughly in line with what you expected?
Raywat Deonandan: It’s exactly what I expected. I mean, it’s tragic to say, but everyone kind of knew — given what we observed in terms of human behaviour over the holidays, given the lateness of being locked down, and given the laxity with which people followed public-health guidance — it was unavoidable that numbers would mount in early January. So, unfortunately, none of this is surprising. Doubly unfortunate, because it’s not surprising: a lot of people don’t seem too put out by it, because they seem to have been steeled for it in some ways. And that’s the troubling part of this: the normalization of suffering. These numbers have become abstract, almost another historical peak — no big deal. Another 50 people dead in the province. People have stopped caring.
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TVO.org: I wanted to talk about how the vaccine rollout has gone so far. There have been a lot of people saying that Canada and the province specifically aren’t doing enough to get vaccines into people. And I’m wondering, how much is this true? And how much is it unavoidable?
Deonandan: So, on the one hand: absolutely, we need more vaccines. No question. And that should be a national effort to get vaccines onto Canadian soil as quickly as we can. So that’s on the federal government to negotiate access.
But the second question is, have we unrolled what we have now quickly enough? I don’t know the answer to that. My feeling is no, we haven’t. And I say that because, one, we had those days over the holidays where the vaccine clinics were closed, ostensibly to give health-care workers a break. But we found out that, of course, there are battalions of doctors who wanted to volunteer their time to get these inoculations done.
On the other hand, you have General [Rick] Hillier saying that we actually have run out of vaccines; we have no shots to give. I don’t know what the right narrative is. Because you’ll see people saying that’s not true. We have tens of thousands in freezers not being shipped out yet. But what I do know is this: you’re hearing genuine stories of non-front-line workers getting the vaccine before people who should, of people on PR teams of hospitals, of CEOs, of people in administrative roles who have no contact with patients, getting vaccines before front-line physicians and nurses. That, to me, is unforgivable.
TVO.org: The Stanford algorithm story from a few weeks ago was dystopian.
Deonandan: So if you do give doses to a hospital to manage, hospitals do great work, and their hearts are in the right place. But every institution is going to have some institutional bias, which means they’re going to take care of take care of their community. So is a hospital best suited to service the needs of long-term-care centres? To service the needs of family doctors? Hopefully, when the Moderna shots become available, it will be more decentralized. And so the provincial criteria for who gets inoculated are one thing, but it’s unclear whether or not those in charge of delivering the vaccines have been following the provincial criteria as closely as they should.
There’s something to be said to for the strategy with which we deploy vaccines. We won’t get to herd immunity until we get 70 to 80 per cent of the population immunized. However, you can get herd effects if you are strategic in how you deploy what you have.
For example, if you get the most vulnerable people immune, then they’re less likely to override the health system. Or you can say, I will give it to those people who are more likely to have multiple contacts. Front-line workers, grocery clerks, people who have an unavoidably large number of contacts every day. That might diminish spread and artificially lower the threshold by which we achieve herd effects. Maybe we should use up all the doses and just inoculate old people: start with those over 80, move down to over 70, and just basically go down that pyramid as more doses become available. And that reduces the fatality rates enormously. I don’t know what the right thing to do is. We’ll be debating this for years to come.
TVO.org: But regardless of which strategy you choose, once the people that you prioritize first are chosen, you still have to get the vaccine to them somehow. And it seems like people are thinking that the government is failing on that front.
Deonandan: There’s a huge logistic area, and that is that the Pfizer shots need that extreme cold chain.
And so that’s why it’s being sent to hospitals — the assumption is that it gets stored in hospitals that have the capacity to do so and can be distributed through there. And there is some controversy there, too, because some will argue that once you defrost the Pfizer shot, you’ve got six hours for it to be used, so you can use those six hours to ship them all around the city from a central location.
But once the Moderna shots arrive in large numbers, those don’t suffer from the same limitations of cold-chain storage and troubleshooting, so it’s much easier to ship them around to more remote areas. And when the AstraZeneca and Janssen shots are approved, they can be stored in even more stable conditions, so the transportation and storage limitations are even less, and they should be more distributable.
But here’s the thing. We know how to distribute vaccines. We do this with the flu vaccine every year. The infrastructure exists through drugstores, doctor’s offices, public-health units. This country, this province, has decades of experience doing things like this. It’ll be mystifying if, in fact, we do not end up doing this as efficiently as we can. It’s understandable that we have some missteps, to be honest: early days — we’re just several weeks into the vaccination process. And I’m optimistic. I think many of these missteps will be worked out in the coming weeks.
Like Israel, which is two-thirds of the population of Ontario: it got a lot of doses and has managed to inoculate a very large proportion of its population very, very quickly. So its rollout plan was extraordinary.
It’s incumbent upon us to get as many shots into arms as we can, especially now that things are really dire, and the new variants are here. So I’m not a fan of looking backwards or second-guessing what we did or could have done, and so forth. But the more important question: What can we do now? What we can do now is negotiate for more doses, investigate whether we buy the dosing regimen to maximize distribution. Can we get away with one shot? Or at least can we delay that second shot? Can we mix and match shots? Can we use the booster from Moderna for the initial Pfizer shot? Probably can, to be honest. So with more data comes more ability to be flexible in how we apply the dosage.
TVO.org: You mentioned that your area of expertise is global health. Is there a concern that, if rich countries like Canada buy up all the doses, people in developing countries might not be able to get vaccinated?
Deonandan: Some people are calling this vaccine apartheid. This is a global pandemnic — that means that it only goes away when the globe makes it go away. If it goes away only in rich countries, that really doesn’t help us a lot. In any part of the world, we risk re-infection or, at the very least, we risk the global economic system.
So international travel is not going to go back to anything resembling 2019 normal until the world is safe. Nobody is safe until everybody is safe. So we must make sure that the poorest parts of the world have access to a vaccine.
The COVAX initiative allows poor countries to buy vaccine that has been sequestered by the rich countries, and Canada is a signatory to COVAX. And we have finally committed to donating our excess doses once we are sure we have excess doses. So we do what we can. But there are definitely issues here involving global equity. What people need to understand is that we help ourselves by helping the rest of the world — we make the disease go away faster. There is no scenario in which it is advantageous not to help the rest of the world become vaccinated.
TVO.org: Some people are speculating that it might be 2024 before developing countries receive their vaccines. Do you think that’s accurate?
Deonandan: I think that’s accurate. And that’s only three years from now. We’ve been overly pessimistic on the rate of vaccine arrival development and distribution every step of the way here, so maybe we’re pessimistic there, too. The beauty of that prediction, though, is that we can force that to be earlier. That’s a matter of political will. So 2024 seems like a reasonable assumption. But with a concerted amount of effort, we can make that 2022.
TVO.org: And will we still be in a pandemic state in 2024?
Deonandan: What is a pandemic? A pandemic has a soft definition. But, to the extent that the WHO declares a pandemic, then they will probably declare this pandemic to be over sometime in 2022, even though the disease might still exist in significant numbers in some countries.
It’s those countries that we’re concerned about. When will we have 2019 levels of normality? I don’t know if we ever will, because we’re always going to have some kind of nervousness about this, and some amount of mitigation will remain.
But, to the extent that we have normality, that individual citizens don’t notice a change has happened — I think we will have that in 2024, to be honest. Depressing, right? Because it takes a while to test the longevity of immunogenic response of vaccines; it takes a long time to figure out how to weave that into our everyday lives, how to make sure that re-infection protocols are established with travellers, etc. This is just the first—not the first but the current-- of what is going to be a series of global public-health crises that threaten us, and we need to remain alert.
TVO.org: I think some of the communication has encouraged people to develop benchmarks — like, oh, maybe by next year, we’ll be able to do concerts. I don’t think I’m alone, though, when I say that, yes, concerts are lovely, but what I would really like to know is, when I can hug my mom? When can I go visit my mom? And that seems to not be a priority for communication, even for public-health officials.
Deonandan: I think you’re right. I think that, on the individual level, those are the benchmarks. Now, it’s hard to answer those questions, because those questions depend entirely on the rate of vaccine distribution — and the big question of exactly how long it lasts and doesn’t actually diminish transmission. To get to those levels of normality of hugging a loved one and so forth, it becomes a priority to prioritize vaccine for operation. Absolutely. Thinking about these decision-makers always thinking about what it means for the supply chain on a national level. But for individuals, what matters is what it means for the goalposts of my personal life to go back to some levels of normality. I think you’d be able to hug your mother with impunity sometime at the end of this year.
I think we’ll have concerts sometime early next year — maybe even sooner. I think we’re going to have sports in school with some mitigation in place in the fall. And I think we’re going to have something resembling international tourism, though highly restrained, by the end of next year. So these are the timelines I would pull out of my hat based entirely on my expectations of vaccine distribution, longevity, and power. I could be 1,000 per cent wrong.
TVO.org: But, basically, no hugging mom until there are widespread vaccines?
Deonandan: That’s the safe thing to say. But really, in your community, we may find diminished transmission. We may find a test-positivity rate well below 1 per cent. We may find no new cases for a couple of weeks. When that happens, then I think it will feel a lot more comfortable doing those things again. And that might happen sooner rather than later. It’s going to take some work. I think you’ll get there sooner than you think. I know we’re fond of being pessimistic with these projections. But I’m an optimist by nature. And we’ll get to the point of human contact on that level before the end of this year.
This interview has been edited and condensed for length and clarity.