Let’s discuss the AstraZeneca vaccine. I am just going to give you some facts. You can make your own decision about the AstraZeneca vaccine.
On March 29th, Canada’s National Advisory Committee on Immunization (NACI) recommended provinces pause on the use of the AstraZeneca-Oxford COVID-19 vaccine on those under the age of 55 because of safety concerns. NACI’s priority is vaccine safety. Their decision came after the European Medicines Agency ( EMA), Europe’s Health Canada equivalent, investigated 25 cases of very rare blood clots out of about 20 million AstraZeneca vaccines given. On March 18th the EMA concluded that the benefits of the AstraZeneca vaccine far outweigh this risk if there is a true increased risk of the blood clots.
Most of these rare blood clots occurred in women under the age of 55 ( 18 out of 25). Thus, NACI’s recommendation to halt the use of the AZ vaccine in this age group pending further review of the ongoing real-time research.
So, 25 cases out of 20 million vaccinations is a risk of about 1 in a million. That means that if there actually is an increased risk, the risk is 1 case of the rare blood clots out of 1 million vaccines given. One in a million.
Let’s shed some light on that: The risk of blood clots developing among new users of oral contraceptive pills ( birth control pills) is 8 out of 10,000. Thirty four out of 10,000 women who use hormone replacement therapy ( HRT ) will develop a blood clot at some point. And, the risk of developing a blood clot in women in general is is 16/100,000.
The Canadian maternal mortality rate ( the rate of death in women during childbirth) is 8.3 deaths per 100,000.
No medical intervention is without risks. The question is, should we take that risk? That is what NACI will try to figure out in the coming weeks. Let’s balance that risk of 1 in a million with the risk of COVID-19.
A new briefing note from a panel of science experts advising the Ontario government on COVID-19 shows a province at a tipping point. Variants that are more deadly are circulating widely, new daily infections have reached the same number at the height of the second wave, and the number of people hospitalized is now more than 20 per cent higher than at the start of the last province-wide lockdown.
These variants are more dangerous and more easily transmitted. They cause 2.5 to 4.1 deaths per 1000 detected cases. That’s deaths. The risk of serious complications with the variants is double the risk of the original COVID-19 virus: 20 out of 100.
Here’s a quote that scared me. “Right now in Ontario, the pandemic is completely out of control,” Dr. Peter Juni, the scientific director and a professor of medicine and epidemiology with the University of Toronto and member of Ontario’s COVID-19 science advisory table.
The AstraZeneca vaccine is over 70% effective up front and almost 100% effective at preventing deaths and hospitalizations from COVID-19. Breathe. It is not time to throw out the baby with the bath water. No blood clots have occurred in people over 60. We should continue using the AstraZeneca vaccine in this age group which is most at risk of serious complications and death from COVID-19.
“Be hard on the problem, not on the people.” – unnamed OMA Executive
When I was President of the Ontario Medical Association (OMA), I had the privilege of touring the province. The tour was during flu shot season, so I took the opportunity to meet many Public Health physicians and staff. They are all good, hard working people who are dedicated to their communities and doing their best to advocate for the health care needs of the population.
Unfortunately, the Public Health system in Ontario (and Canada) is fragmented and disjointed. This really impeded the ability of Public Health to act in a unified manor prior to the pandemic. But because Public Health wasn’t as “visible” at the time, the flaws in the system remained hidden.
To understand just how this fragmentation affected our health, one only looks at the situation around trans fats. I wrote about this previously, but in short:
– We’ve known since 1993 that trans fats are linked to increased heart disease
– We’ve known since 1995 that Canadians are one of the highest consumers of trans fats in the world
– The results were so good that many other European countries followed suit.
If we apply the Denmark results to Canada, we could prevent 600 heart attacks a year. Banning trans fats would seem to be a no-brainer, and clearly the type of thing Public Health should effectively advocate for.
But here in Ontario, outside of the City of Toronto trying to ban trans fats in restaurants in 2007 not much has been done about this. Part of this is because Ontario has 35 different Public Health units, who all function independently. They may not even have the same software when collecting data, and some still use paper charts. Because they all function independently, just because Toronto Public Health wants a ban, doesn’t mean all the other units would even know about it, much less share information on it, or advocate for it. And of course, every Province and Territory has their own autonomous Public Health System.
It wasn’t even until 2017 that Health Canada got around to proposing a ban on trans fats, and 4 years later this still hasn’t happened. It’s worthwhile noting that over 10,000 heart attacks could have been prevented if we had acted at the same time as Denmark.
If in “normal”, non-pandemic times, the Public Health system was so fragmented, and disjointed, that something this straightforward couldn’t be accomplished, how would they perform in a once in century pandemic?
The answer, sadly, is not very well.
Just as the various Public Health Units couldn’t co-ordinate on the same message for Trans Fats, it appears the various units can’t co-ordinate on the same messaging around COVID. Case in point, on Nov 4, 2020, Health Canada finally (!) announced that yes, indeed, the coronavirus has airborne spread, and all facilities should take airborne precautions.
Yet a look at the website for my Public Health unit (Simcoe Muskoka) on Jan 10, 2021 (2.5 months later!) still shows the same guidelines that’s before the announcement. Namely, that the virus is spread through droplets and so cleaning surfaces is more important.
So here we have two different messages coming from public health authorities.
By comparison, take a look at Japan. Japan decided back in February 2020 that the virus was aerosolized. They too have many regional public health offices, however, the regional branches send the information to the national office, and the national office makes decisions. Those decisions are clearly communicated to the public, so the same message goes through the country.
They very quickly focused on things such as air purifiers with HEPA filters in rooms, improving ventilation by leaving windows open (even in the crowded community trains) mask wearing, and improved HVAC systems.
But it’s not just messaging that’s the problem. Public Health Units are hampered by their archaic systems from adequately preforming the test/trace/isolate process so important to controlling the spread of COVID19.
My practice is close to the border of the Simcoe Muskoka District Health and the Grey Bruce Health Unit. If one of my patients comes down with a reportable illness, I have to figure out which health unit to report to. But they use separate forms. Additionally because they use separate data systems, they can’t share information between the two.
Supposing one of my patients were test to positive for COVID-19. What if they live in Grey Bruce, but work in Simcoe Muskoka. Who should I report this to? And more importantly who is responsible for the contact tracing considering they work in one area and live in another? Especially since they can’t share data.
The result? Effective test/trace/isolate does not occur in Canada.
Compare this to South Korea. South Korea has multiple regional offices for public health, but they’re integrated by the Korean Ministry of Health and Welfare (KMHW). They share software, and so can share data and information.
By having all of Public Health integrated, South Korea was able to have one source for information. So not only did they have a consistent message (the KMHW gave two press conferences a day), but they were able to effectively test/trace/isolate.
Canada’s response to the COVID pandemic is among the worst in the world. Only the fact that we are next door to a country that has had arguably the worst response in the world seems to prevent Canadians from recognizing this fact. If there is one learning that me must take forward from this, it is that lack of an integrated, seamless and co-ordinated Public Health system has cost us many lives.
As a country, we need to support the people working in Public Health by improving the systems they have, so they can protect us in the future.
Note: This blog is based on the first part of a presentation I gave to the Public Health Youth Association of Canada (my thanks to them for asking me to speak). If you are suffering from insomnia, or if you are generally good person and want to support young people who are keen to improve the world, feel free to watch the presentation here:
Recently, many physicians offices have been inundated with requests for the so called “high dose” flu shot. I know I’ve had many patients ask in my own office, and this is the result of all the publicity around these shots. Pharmacies were specifically advertising that they had the high dose shots available. Heck some pharmacies even offered customers points for getting your shots. Until of course, they ran out. (Memo to pharmacies – unlike Teslas, generally not a good idea to advertise something you can’t deliver on time).
Of course once they ran out came the inevitable concerns expressed about why people couldn’t get a “high dose” shot themselves. I have also heard some isolated reports in my community about people waiting to get their flu shot until the high dose were back in supply.
But here’s the thing. There is no evidence to suggest that the high dose flu shot is actually better than the current standard dose shot. Seriously.
In 2014, a study was done looking at the high dose versus regular flu shots, particularly in older patients. The study clearly showed that there was a higher immune response in older patients with the high dose shot. But from a clinical perspective, it really only made a minor (although what statisticians will call a statistically significant) difference. 1.9% of people who got the standard flu shot went on to get the flu, and 1.4% of people who got the high dose flu shot went on to get the flu, for an effective difference of 0.5%. All this hype for 0.5%??
But more importantly, that study looked at what are called trivalent flu vaccines. In essence, both the standard and the high dose vaccines in the study were good against three strains of the flu.
However, in Ontario, our standard dose flu shot is a quadrivalent. It’s good against four strains of the flu. The high dose continues to be a trivalent. So the option for people in Ontario is to get a flu shot that has a regular dose against four strains, or a high dose shot that is good against three strains only.
Importantly, there has not been a head to head study between the high dose trivalent and the standard dose quadrivalent used in Ontario. Which means no one really knows which vaccine is better.
Heck even the Public Health Ontario Fact Sheet on flu vaccines states there is “insufficient evidence” to recommend one over the other. There is some supposition about the extra B strain that is covered in the quadrivalent vaccine not being as common in those over 65, and perhaps having a lower disease burden, but it’s not really clear cut.
So what should you do?
As I mentioned in my last blog, you should wait until November to get your flu shot. It now being November – GET IT! If you are over 65 and are unable to get the high dose, don’t sweat it, just get the standard one. Because frankly the protection you get from that is still really really good (I mean why all this fuss over a measly 0.5%??). But don’t put off getting your shot now just to wait and see if more high dose vaccines are coming.
It’s time to protect yourself and your loved ones. Both flu shots are good. Get whichever one you can, and let’s help each other stay safe.
Several years ago, one of my colleagues was having a disagreement with an external health care agency. She’s a very bright young family physician, and is extremely passionate about one part of comprehensive family medicine care. She really felt the external agency was failing in providing a reasonable level of service for one group of marginalized patients. In particular, she felt the agency’s process for accepting referrals was deeply flawed.
After months of advocacy by her, the agency finally reviewed their intake process. They then pronounced that everything was ok, because 90% of the referrals were processed accordingly.
In response, my tenacious colleague sent an email to all the family docs in the area, asking them for feedback on the referral process. She the proceeded to blast said agency for the 90% processing rate. “If a server at McDonald’s got the order wrong 10% of the time, would he still have a job?” was the line in her email that really got everyone’s attention. As a result, my colleagues sent feedback, the external agency’s response was proven inadequate, and changes were made. In her own way, my colleague was following the wisdom of Ruth Bader Ginsburg:
It also shows, in one neat example why physician autonomy is so important to patient care. Because without that autonomy, and independence, we can’t speak out. We can’t advocate for our patients even if it makes bureaucrats uncomfortable. We can’t expose those situations where patient care has been compromised.
This is, of course, exactly what those who want to take autonomy away from us want. For the most part this includes two types of people. First are health care bureaucrats, who feel that because they control the purse strings, everything should be done their way, and no pesky front line physicians should dare question their judgement or expose their flaws. The second group consists of a small number of physicians, who, while well intentioned, feel that physicians autonomy impedes whatever fancy new health program they want to implement.
Suppose you are an employee in the IT department of a corporation. You make a statement like say, “If our legal department worked at McDonald’s they would get fired because they get orders wrong 10% of the time.” What happens then? Human Resources gets involved, you get called out for making derogatory comments, the CEO might even get involved, you get disciplined and basically told to shut up. Even (especially?) if you are right in the first place.
This is exactly what those who oppose physician autonomy want.
The anti-autonomy crowd feels that physicians resist change. Therefore, the thinking goes, physicians will use their autonomy and independence to impede whatever new program/model/team is being promoted. Hence, autonomy must be curtailed so physicians can do what they are told, and accept whatever the powers that be tell them is good for them.
However, this couldn’t be further from the truth. The vast majority of physicians are open to new ways of doing things. If they truly believe a new process will help their patients, and help their lives, they will adapt. This is why we use new medications, new treatment protocols and yes, newer models of health care delivery than we used in the past. Medicine would not have changed so much in the past 25 years, if it wasn’t for the willingness of physicians to explore newer and different methods of delivering health care.
But as my friend’s example shows (and there are many like hers), what is essential to the provision of good patient care, is for physicians to retain their ability to speak out. My friend saw an area where a health care agency was failing a group of patients. Because she didn’t have to fear retribution in the form of being hauled up in front of Human Resources, she was able to effectively advocate for patients (who in this case happened to be too frail to advocate for themselves). Eventually, due to her persistence, the agency recognized their errors and fixed their flawed process.
In much the same way as we explore transforming the health system again (in Ontario these are to be done with the Ontario Health Teams or OHTs), it is fundamentally important to ensure that physician autonomy is protected in these models. This will allow physicians to speak up if the implementation plans are not going the way they should, or if programs promoted by the leaders are not really going to help patients. While painful for those in charge to hear criticisms, it results in better outcomes in the long run because the new programs will be better, stronger and more effective.
Let’s hope that as the new OHTs are developed (full disclosure, I support the concept) the message of the essential nature of physician autonomy is not lost. Physician autonomy has allowed us to be the best possible advocates for patient care in the past. If we can no longer, as Ginsburg urged, fight for the things we care about, it will be the patients who suffer.
An advantage of being old is that whatever is happening, you have likely seen it, or something like it before. Every so often, society undergoes an upheaval and people have to change behaviours. For those of us who were around in the 1980s, there are some stark parallels to what happened then, and what society must do now in 2020.
The early 1980s were a different time not only for how we lived as a society, but for how medicine was practiced. This was particularly true with how we handled body fluids. As surprising as it may be to some younger readers, there was no such thing as universal body fluid precautions back them. If you had a known blood born illness like hepatitis, then sure, extra precautions were taken. But not for every body. When I was in medical school, there were multiple stories of a particularly nasty vascular surgeon who would squirt blood on trainees during surgery if they got an answer wrong to his questions. Needle prick injuries were routinely ignored. There was not a robust sharps disposal system. In short, it was very different.
A huge shift in society, and medicine, came when reports of a novel virus (sound familiar?) became publicized. This virus was new, deadly, and little was know about it. At first, this strange new illness seemed to only affect gay men. This led to all sorts of additional discrimination against the gay community, and even more ostracization then they were already experiencing. Mainstream media outlets routinely referred to it as “The Gay Plague” which clearly didn’t help matters. This also led to whack job conspiracy theories about its origins, some of which persist to this day.
This strange new illness was, of course, eventually named “Acquired Immune Deficiency Syndrome” or AIDS and the virus that causes it was identified (Human Immunodeficiency Virus or HIV). It was recognized that body fluid transmission could spread it and that it was not limited by sexual orientation. We learned it was possible to carry the virus and not have symptoms and you could get it from anyone.
And so, the age of universal blood and body fluid precautions began, and policies around this were implemented in hospitals and other health facilities between 1985-1988.
But there was also a shift in how society responded. Until then, most public service announcements around Sexually Transmitted Disease (like this painfully dated one from 1969) focused simply on encouraging people to get treatment after the fact. And accepting that it was possible for you (yes, sweet innocent you) to get an STD.
AIDS changed all that. Suddenly, an STD could be deadly. Suddenly there was no cure or vaccine. Suddenly, just getting treatment wasn’t an option, and education around prevention was mandatory.
With education, the public took precautions. “No glove, no love” was a popular catchphrase used to promote latex condom use as these were proven to significantly reduce the risk of transmission of STDs (including HIV). Public service announcements shifted to openly talking about prevention.
In short, people and society adapted, and changed behaviours to deal with this new virus.
Today of course, we are faced with a novel new virus, that is clearly deadly and is widely publicized. Little was know about it at the start, and we continue to learn about it. The virus seems to have originated out of China, and this has led to all sorts of anti-Asian racism (including from the President of the United States). There are whack job conspiracy theories about it. As we learn more about the virus, we know asymptomatic spread is possible, and that, yet again, anyone can get it. There is no vaccine (and despite Dr. Fauci’s optimism I’m not holding my breath) and no effective cure.
In response, hospitals and other health facilities are implementing new polices around Personal Protective Equipment (PPE). Hospitals are taking extra precautions around elective surgery as the risk of mortality in patients who get COVID19 infections peri-operatively is ridiculously high. In my office I now see patients wearing a mask, eye protection, and surgical scrubs that I immediately remove after my day is done.
And now too, society will be asked to change in response to this most awful virus. The simplest thing to do of course, is to wear masks when you are in an indoor public place, or better yet whenever you leave the house. As mentioned in an earlier blog, one only has to look at Japan where there was poor social distancing, packed public transit and no closure of their famous karaoke bars, but people wore masks, and the number of infections was extremely low. Wearing them also is key to restarting the economy so we can get on with our lives.
The big difference between the AIDS epidemic of the 1980s and COVID19 now is, of course, the economic costs. The economy was never shut down then, and the kind of wholesale level of job loss we are experiencing now in (hopefully) once in a life time.
But if we are to get the economy running (and we must for a whole bunch of reasons, including the fact a good job improves overall health care), then society will need to adapt again. We did it forty years ago, and I believe we can do it again.