Should Ontario adopt a first-shots-first approach to vaccines?

OPINION: If one shot of vaccine massively reduces the odds of death or serious hospitalization, perhaps that’s something the province should consider
By John Michael McGrath - Published on Mar 02, 2021
Limited but suggestive data suggest that a single dose of either the Pfizer or Moderna vaccines could be effective. (Andrew Vaughan/CP)



The news arrived in reporters’ inboxes late in the day Monday: Ontario is willing to consider extending the period of time between first and second doses of the Pfizer-BioNTech and Moderna vaccines if it gets the all-clear from the federal National Advisory Committee on Immunization. This would follow the decisions made first by Quebec and announced earlier on Monday in British Columbia.

“By safely extending the dose interval, Ontario would reach more at-risk Ontarians with our vaccine rollout, and potentially offer the vaccine to the general population much earlier than originally planned,” said Minister of Health Christine Elliott and Solicitor General Sylvia Jones in an emailed statement.

As everyone knows by now, the Pfizer and Moderna vaccines require two doses, and they were initially approved by medical regulators around the world based on spacing those two doses out by several weeks — 21 days in the case of Pfizer, and 28 days for Moderna. But as early as December, there were limited but suggestive data showing that even a single dose of either vaccine could be effective, especially when it comes to reducing the two outcomes governments care most about: hospitalizations and deaths.

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The course of subsequent vaccination campaigns in other countries has borne this theory out: the United Kingdom announced Monday that a single dose of either the Pfizer or AstraZeneca vaccine (the latter has just been approved for use in Canada) cut hospitalizations by 80 per cent. Evidence like that is behind the advocacy for what’s been branded “first shots first,” or “first doses first,” which involves trying to get as many people partially immunized as possible before following up with second doses. This is effectively the decision B.C. announced Monday when it said it would space out the two shots by as much as four months. That announcement, in turn, prompted Ontario’s missive.

(I can’t help but point out that, not even seven days ago, Premier Doug Ford was using Quebec’s example as a defence for Ontario’s own vaccination record; his ministers are now all but admitting the François Legault government was on to something.)

But before the ink was dry on B.C.’s announcement, the counteroffensive was already underway: the federal chief science adviser, Mona Nemer, direly warned in an interview with the CBC that B.C.’s decision amounted to a “population-level experiment” and argued that governments should “stick with the data and with the great science that give us these fantastic vaccines — and not tinker with it.”

It's fair enough to call this a population-level experiment, but only if we first acknowledge that it’s just the most recent experiment we’ve conducted on Canadians during the pandemic. We are, right now, experimenting on millions of people (including young children) with any number of public-health policies. The short-list would include investigating the mental and physical effects of long-term confinement at home; the academic and social-equity consequences of remote versus in-person school for young children; and the public-health consequences of hospitals being reduced to emergency-only services. All of these experiments have imposed real, tangible harms on people, but we’ve justified them by saying it’s necessary to save lives. Spacing out the first and second doses of vaccines could also cause individual harms — we should be honest about that — but those harms can be evaluated on exactly the same grounds.

Is first-shots-first an experiment? Sure it is. Throw it on the pile with the rest of them.

As for the argument that we should “stick to the science”— well, which science? Nemer is asserting a precision in the facts that simply doesn’t exist, not even in the data used to approve Pfizer and Moderna. The results from the U.K. are not a rigorously controlled clinical trial published in a peer-reviewed journal, but that doesn’t mean we should pretend the data don’t exist. Controversies persist here in Canada, too: NACI warned Monday that the AstraZeneca vaccine isn’t recommended for people over 65; Health Canada’s approval of the vaccine didn’t include that caveat. Science has evolved continuously throughout the pandemic — some of us are old enough to remember when public-health officers were imploring people not to wear masks — and there’s no reason to believe that it’s going to stop doing so.

Finally, to Nemer’s allegation of “tinkering”: people apparently need to be reminded that the goal for 2021 is not actually to have every Canadian vaccinated against COVID-19 on the strict schedule approved by Health Canada’s regulators. It’s to stop Canadians from dying of COVID-19 and to get provincial health-care systems back to some kind of pre-COVID normalcy; vaccines are a means to those ends, not an end in themselves. Some countries have largely gotten to where we want to be without vaccines at all (here’s looking at you, New Zealand). If one shot of the Pfizer, Moderna, or AstraZeneca vaccines massively reduces the odds of death or serious hospitalization, that’s absolutely something the provinces are within their rights to weigh.

But not a single word I’ve written above means that Ontario should or must adopt a first-shots-first strategy tomorrow, even if I personally think the arguments are compelling. Elliott’s Monday-afternoon statement implies the government is going to wait for NACI, and that’s reasonable, even if NACI’s recommendations are in no way binding on the province. It would also be reasonable if Ontario never pursued first-shots-first at all, no matter what NACI says. We’ve spent a year living with ambiguous data and policy grey areas, and as much as people want clarity and precision, the pandemic has truly illuminated the fact that, in the end, it’s just judgment calls all the way down. Whatever Ontario chooses to do next, we’re going to have to live with that ambiguity a while longer.

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