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HealthCare 365 Update
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Dear HealthCare 365 Family,

If you have any concerns about your health or questions for our team, please call the office or email your care coordinator. We continue to work regular hours, and  prioritize virtual options when appropriate. We are here for you and are available to assess and assist with your concerns. The medical team will evaluate all health concerns to determine if you require an office visit.

If you are having difficulty breathing or experiencing other severe symptoms please call 911 immediately.
A PERSONAL MESSAGE FROM DR. KOHUT

What a roller coaster of a week this has been!
We are finally seeing news that the restrictions on our activities were bearing fruit. COVID-19 cases in Ontario are dropping. Yesterday, May 13th, 2759 new COVID-19 cases were documented. It appears community transmission rates are stabilizing and slowly declining. Last week, positive COVID-19 testing was down to 6%. For the first time in weeks COVID-19 ICU bed occupancy was under 900 beds.

Canadians are being vaccinated in larger numbers, due to improved vaccine supply. Large quantities of vaccines (mostly Pfizer and smaller amounts of Moderna) are coming to Canada this month and regularly until July.

On May 5th, NACI (National Advisory Committee on Immunization) makes a strong preferential recommendation for mRNA vaccines (Pfizer and Moderna) for all Canadians.There is an uproar! Accusations of receiving an inferior vaccine, or being misinformed about vaccines, about receiving a second-class vaccine, hits the press with a fury. How something is said- matters. Clearly. Just look at the reaction.

Today, I am going to walk through these recommendations , comment on vaccine mixing and  on what’s in store ahead .

To those of you who are looking for brevity, I apologize in advance- Help me Rhonda is once again longer.

V

AZ VACCINE Q & A 

What do I  need to know about the AZ vaccine ?

  1.  If you had had the AZ vaccine and 4 weeks have passed, there is no risk for VITT( Vaccine Induced Thrombotic Thrombocytopenia). The unusual immune mediated clotting  disorder  associated with  the Astrazeneca -AZ vaccine). For more details see previous Help Me Rhonda.
  2.  What do I need to know about VITT 

 If you have any signs of VITT,  go to the Emergency Department of a hospital  with your AZ vaccine record!

3. What do I do about my second shot, if my first one was AZ?  See discussions below  and  NACI recommendations.

NACI RECOMMENDATIONS ON PREFERRED VACCINES

NACI recommends that the AstraZeneca/COVISHIELD or Janssen/Johnson & Johnson vaccines (once available) may be offered to Canadians 30 years of age and older if:

  1. The benefits outweigh risks of waiting for an mRNA vaccine.
  2. The decision to receive the vaccine is informed by risks and consequences of VITT.
  3.  The delay to receive an mRNA vaccine is substantial.

NACI outlines that risk-benefit decisions should be informed by several factors including:

  1. The local COVID-19 epidemic conditions.
  2. Local vaccine supply
  3. An individual’s risk of severe illness and death if they develop COVID-19.
  4. And their risk of exposure to the SARS-CoV-2 virus.

Let’s look at what was behind the statements to understand the reasons for these statements. Maybe then we can give the Chair and Vice Chair of NACI a bit of a break.

I have said this before, the world of COVID-19 is an ever - changing landscape. Decisions by physicians, (on the delivery of care to COVID-19 patients), advisory agencies, and government agencies on a recommended course of action, are made with the data available at that time. That data changes and evolves. The ground shifts under our feet. Recommendations are made weighing Risk and Benefit.
 

March, 2021 NACI recommendations:

When the original NACI recommendations on vaccination using AZ vaccine were made, we were in the worst of wave 3. Vaccine supply in Canada was low..
3 % of Canadians were fully vaccinated, and 12% of Ontarians had received one dose of vaccine. 
The pandemic was raging.  Infection rates were climbing, hospital admissions were on the rise, Hospital ICUs were overflowing, the average age in the hospital and ICU  (Intensive Care Units) was under 50. Unless emergent, the treatment of most other health conditions was on hold. There was simply no ability to provide additional care. The primary concern was to vaccinate as many people as possible to slow the rate of infection, reduce variant evolution, decrease the number of hospitalizations, ICU admissions and deaths. Pfizer ’s vaccine production was delayed, as was Moderna’s. The available vaccine was AZ. The protection against hospitalization, ICU admission, and death was comparable between vaccines (Pfizer, Moderna and AZ). At that time, (March 2021) VITT (or vaccine-induced thrombotic thrombocytopenia) was emerging as a risk, and the suspected numbers quoted varied between 1/200,000- 1/500,000, even 1/million. The consequences of this (as yet not clarified) event were however catastrophic. The overarching message to the public was - "we are actively monitoring to this serious issue" (recall from previous Help Me Rhonda that adverse reactions to vaccines are continually monitored and vaccine safety- “safety signal” is the highest level of concern) but “we need to get vaccine into lots of people”.

Fast forward to beginning of May 2021:

Many of the systemic  issues remain- hospitals and ICU’s  are strained with COVID patients. 
BUT...
1. 40 % of the population of Ontario has had  one dose of vaccine. (now it’s 50%).
2. Safety signal.

800,000 Canadians have received the AZ vaccine to date. The “safety signal” on VITT is triggering more frequently in Canada, and over the world.

“Over last few days, there have been increased reports of VITT, with a rate of 1.7 per 100,000 doses administered," said Dr. Williams (Chief Medical Officer in Ontario). 12 Canadians have been reported to have VITT to date,, three of whom died. As more real-world data was shared, the VITT numbers continued to rise. Within a few weeks VITT numbers in the world were 1/26,000- 1/100,000. (this is case data ‘catching up') In Canada the VITT risk is now estimated at 1/50,000 (with some cases still being evaluated). The risk of dying  from VITT is  1 in 5= 20%!

3. While many younger patients are very sick from COVID-19, their risk of death remains low, read hereClose to 25,000 people in Canada have died from COVID-19. 1.6% (375) are under age 50, and 3% (712) are people in their 50s, read here. Compare the risk of dying  from VITT.  It  is 1 in 5-= 20%!

4. The risk -benefit of the AZ vaccine has changed. A personal risk for getting infected with COVID-19 has to be evaluated against the increasingly frequent, very serious risk of VTT and possible death (1 out of five).

5. COVID-19 "Hot spots” persist. “Hot spots” are both geographic and population based. Peel, Toronto, Durham,  regions have high COVID-19 case counts. Furthermore, unvaccinated individuals employed in high risk environments, for example teachers, personal care workers, store employees, workers in the food / meat packing industries, etc, transportation industries, and youth are at high risk for exposure to COVID-19. If you are in these groups (page 11-13) and still unprotected you need vaccination. Your risk for infection with COVID-19 remains high.

6. AZ vaccine is NOT the only vaccine available. More Pfizer vaccine is arriving weekly. In fact, 2 million doses of Pfizer vaccine will arrive weekly now until mid-July. That is 20 million doses of Pfizer vaccine alone! True - distribution of the COVID-19 vaccine remains a challenge. To combat this and get at hotspots, Increased numbers of “pop up” clinics are dotting the landscape.

Dr. Andrew Morris (Infectious Disease physician, Professor Department of Medicine Faculty of Medicine University of Toronto, and Medical Director, Antimicrobial Stewardship Program Sinai Health System/University Health Network) paraphrases NACI and asks…"why would you take the additional blood clot risk when there are safer alternatives with the Pfizer and Moderna vaccines? And they are right. The caveat is if you have a really high risk of infection (see some of my reasons above) and you cannot access the mRNA vaccine (Pfizer or Moderna) get AZ vaccine”.

Vaccine remorse.

The belief that those individuals that received the AZ vaccine were given an inferior product or somehow hoodwinked into not getting a “lousy” vaccine is simply not true. To quote Dr. Andrew Morris. again, “In a raging pandemic, getting much, much, much safer with a vaccine that has a proven research and real life (Hello UK!) experience of protecting incredibly well from death or severe illness from COVID-19, when you had no other vaccine access, was the right thing to do. Rest assured. You are very well protected. So, up until several weeks ago, the aphorism "any first shot is your best shot” was correct".

What about the risk of VITT after a Second dose of AZ vaccine?

Does the second dose with AZ vaccine carry a different risk of VITT? I don’t’ know. Some reports have quoted 2 per million. Are these numbers accurate.? Remember VITT was not picked up in sufficient numbers to raise concerns about a connection to AZ vaccine until millions of doses were administered. There have not been enough second doses administered to evaluate this risk… NACI is tracking this data and will advise on it as well.

Expert opinion on further use of the AZ vaccine in Canada varies. Evaluating Risk/benefit data is complex. Dr. Morris believes that AZ vaccine should no longer be used in Canada, now that mRNA vaccines are in good supply.  Dr. Rakowsky's (cardiologist UHN) comments are included here. NACI has stated mRNA are preferred vaccines, but left room for AZ vaccine use in specific circumstances.  Each of us vaccinated with AZ vaccine, will now have to figure out where we stand on the second dose.

Bottom line:

 If you are 30+y, and belong to the high-risk group of individuals that are not yet vaccinated, you need to be vaccinated. iIt is now your choice which vaccine to take. You have heard the risks for VITT. You know the COVID-19 infection numbers. If you have a high risk of infection and you cannot get the mRNA vaccine, consider get the AZ vaccine.  However, there is ample mRNA vaccine coming to Canada every week. If you are 18-29 y or less you are able to get the mRNA vaccine. At present, the AZ vaccine remains available to Canadians ages 30 and older.

Lasting immunity:

It is only after the second dose of vaccine in all 3 vaccines (Pfizer, Moderna and AZ vaccine) that enhanced long lasting Immunity occurs (in all 3 vaccines).


British study Com-COV - first study to look at vaccine combinations - is expected in June 2021.

This Study is looking at the following dosing schedules:
  • First and second dose of Pfizer-vaccine.
  • First and Second dose of AZ vaccine.
  • First dose of AstraZeneca-Oxford vaccine, second dose of Pfizer vaccine.
  • First dose of Pfizer vaccine, and Second dose of AstraZeneca-Oxford vaccine.

On May 12 2021, the Lancet (a prestigious peer reviewed medical journal) reviewed some of the findings of combined vaccines in a preliminary communication (but not peer reviewed) of the data. This data is focused only on side effects from 4 weeks post vaccination and 12 weeks post vaccination in the above groups.Side effects such as feverishness, chills, fatigue, headache, joint pain, feeling unwell, and muscle aches were increased in the vaccine combinations compared to same vaccine dosing.There were no serious adverse reactions, no hospitalizations and most of the symptoms occurred within 48 hours of immunization and were short-lived. Paracetamol (like our Tylenol) use was more common.Further evaluation of side effects and effectiveness of "Mix and Match" vaccination is pending.

VACCINE LONGEVITY

How long does immunity last after the second vaccine dose of the same vaccine?

At least 6 months, (Pfizer data). More real-world data accumulates as more people are fully vaccinated.

JOHNSON AND JOHNSON VACCINE

Health Canada, approves JJ vaccine (Johnson and Johnson). After concerns were raised that the vaccine arriving in Canada was from a manufacturing plant in Baltimore where quality control problems existed,  Health Canada decided to do its own testing on the quality of the vaccine.  Vaccine rollout is delayed.

Like AZ this is a viral vector vaccine.

JJ has an estimated risk (now) of VITT at 1/500.000.

It is a single dose vaccine. In Canada and in the world, interest for JJ vaccine access is particularly high to protect populations that have less regular contact with the healthcare system.

 WHAT NOW? ARE WE REALLY GETTING AHEAD OF THIS PANDEMIC?

Again, to quote Dr. Morris:

1. For a country, in the short term, maximizing vaccinations while controlling cases until a large majority of people are immunized can offer amazing freedoms—at least in the short term.

2. The biggest threats to freedom and security are the emergence and introduction of immunity-resistant variants.

3. The best way to control the emergence of variants is to ensure global vaccination.

In Ontario, and now Alberta and Manitoba, there are still too many active COVID-19 cases and too many patients in the ICU. In Toronto, Sunnybrook Hospital is still admitting COVID-19 patients to mobile health units to decrease the pressure on the hospital system. Many COVID-19 patients are being monitored at home by the Infectious Disease Staff in the hospitals. We are not out of the woods yet. It is not time to loosen all the restrictions. The OMA today stated its position clearly. It's not time to loosen restriction generally, but for mental health reasons some restrictions should be lifted / read here.

FINAL COMMENTS

Hang in!  For most Canadians, there is hope for a better summer. Please do not let your guard down. Continue to follow the recommendations on masking ,distancing and hygiene. Avoid letting “caution go to the winds” this May long weekend. Let’s work together to help avoid a surge of COVID-19 cases after the long weekend. We need our COVID-19 numbers to continue to drop. Once the numbers are under 1000 cases, restrictions will loosen. With any luck, the communication and goals set by governments in the next weeks will be clear. Summer will be easier. 

Get outside. Be active. Stay socially engaged- however you can, while following recommendations.

Fall will be better. While wearing masks may not disappear completely, we will once again see faces of those in our close bubbles before the end of the year!

If you have any further questions about your health, vaccination, or any other health topics,  all of us in the HC365 health team are here for you.

Stay safe, stay well, stay healthy.

V

If you have any questions please call our office and speak with any member of our medical staff.


Wishing you health, safety and enjoyable family time!

The HealthCare 365 Team
Copyright © 2021 HealthCare 365, All rights reserved.


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