TORONTO —
Developing a COVID-19 vaccine is a huge undertaking. Scientists around the world are working to find a way to immunize humans against a virus that nobody knew anything about even six months ago, and get the vaccine into production in a far shorter timeframe than the research process normally allows.
But once they succeed, public health leaders will be left with major dilemmas of their own – ones less about the practical aspects of stopping the novel coronavirus than the ethical problems that accompany a vaccine.
Should the focus be on decreasing the number of cases, or the number of deaths? Is protecting those most at risk of suffering serious complications worth letting the virus continue to run relatively unchecked in the population at large? Will all parts of Canada have to follow the same rules, or does it make sense to use different strategies in different regions?
In short, who gets to be at the front of the line?
HEALTH-CARE WORKERS, THEN WHO?
There is actually widespread agreement on who should be vaccinated first: health-care workers, both to show appreciation for them putting themselves in harm’s way by treating COVID-19 patients and to avoid staffing shortages in the sector by immunizing workers to the disease.
Once all the health-care workers have been vaccinated, though, it’s not at all clear who should be next.
“After health-care workers, it gets a little tricky,” Alison Thompson, an assistant professor specializing in public health ethics at the University of Toronto’s Dalla Lana School of Public Health, told CTVNews.ca Wednesday via telephone.
Normally, the goal of a vaccination program is to promote herd immunity – building up enough resistance to the virus that it is unable to spread, and thus dies out. Due to the urgency of the COVID-19 pandemic, though, Thompson said there might be an argument for minimizing the number of deaths in vulnerable populations before embarking on a herd immunity campaign.
A decision to focus on vulnerable groups comes with its own predicaments. Should seniors be prioritized over those who have underlying health conditions? What about employees in risky workplaces, or those whose immunity to the virus has been weakened by poverty and poor nutrition?
There’s another problem, too: vaccine candidates are being rushed through the research process. What normally takes years of development is being compressed into a timeframe that could be less than 12 months.
Although clinical trials of potential vaccines will still involve watching for signs of safety concerns, the shortened research period means long-term effects will not be fully understood when a successful vaccine is first given to the public
If the immunocompromised are among the first to be given a vaccine, Thompson said, complications could ensue.
“If you do target vulnerable populations … after health-care workers, it can cause problems,” she said.
“Their vulnerability to the virus can, perhaps, also make them more vulnerable to safety and effectiveness issues which we won’t know about.”
LEARNING FROM HISTORY, AND AI
One group of Canadian researchers is looking to take the decision out of human hands to a certain extent. Professors at three universities in Ontario and Nova Scotia are building an artificial intelligence model that they believe will be able to analyze all the factors at play and provide guidance on how to most effectively deploy vaccines.
Daniel Ashlock, a math professor at the University of Guelph, said in a press release that the model will be made freely available to public-health decision makers, potentially as soon as late this summer.
“Knowing who, how and where to vaccine first is critically important to mitigating the spread of the virus,” he said, suggesting that the tool could be used to determine whether vaccinating grocery store workers or vulnerable populations will have a greater effect on public health, for example.
When making those sorts of decisions, public health officials may also look to guidance that was created in preparation for another pandemic – one of influenza.
The Public Health Agency of Canada (PHAC)’s planning guidance for a flu pandemic, which was last updated in 2018, includes 28 questions meant to inform decisions around who to vaccinate first, covering everything from the characteristics of the vaccine itself to what is happening elsewhere in the world to political considerations.
For a flu vaccine, it suggests likely target groups – in no particular order – could include those at highest risk of suffering a severe outcome from influenza, healthy children and adults who can help build up herd immunity, health-care workers, others working or living in high-risk settings, and those most likely to transmit the virus to those most likely to die from it.
The document also notes the inherent risks of pandemic vaccinations, including that a vaccine might not be 100 per cent effective, that availability could be limited and that not everyone might be willing to receive the vaccine.
Thompson said the basic principles of the vaccination strategy outlined in the documents could be applied to a COVID-19 vaccine. She said some of the specific advice might not be relevant, including the suggestion to prioritize vaccinating healthy children.
“There are still so many questions about the role of children in transmitting this virus,” she said.
HOW MUCH CAN THE FEDS DO?
There are also questions around how much PHAC and the federal government will be able to mandate. The flu pandemic guidance specifically notes that it “is not an actual response plan” and that provinces and territories ultimately have jurisdiction over most aspects of pandemic response, while the federal role is largely limited to procuring supplies, overseeing research and building a national consensus.
Thompson said she would like to see the government work toward a national strategy with full buy-in from each province and territory, especially because of the amount of “cross-border activity” and travel happening within the country.
“It may not make a lot of sense from an epidemiological perspective to not do that, but it also morally might be problematic if one province’s or territory’s strategy is not equitable with the rest of the country,” she said.
Dr. Theresa Tam, Canada’s chief public health officer, has said that the government has no plans to order provinces and territories to make vaccinations mandatory. Alberta, for one, has said that it will not require vaccinations.
Tam said June 2 that the government has begun procuring the supplies it will need to conduct “mass vaccinations” and planning for how vaccines will be administered once they are approved for use.
What remains to be seen is how easy it will be for Canada to obtain a vaccine that is developed outside the country. The Canadian Center for Vaccinology at Dalhousie University in Halifax is conducting a clinical trial of one vaccine candidate, but no other potential vaccines have been approved for trial here. If another vaccine is found to be safe and approved for manufacturing first, Canada may find itself as one of many countries jockeying to import it before production can ramp up.
“Whoever does get the vaccine first is going to have a lot of power,” Thompson said.
Many countries, including Canada, China and the U.S., have vowed to consider a vaccine a global public good and make it available wherever it is needed most.
That creates other ethical concerns, as the need to protect Canadians will be balanced against the concerns of those in countries where proper physical distancing threatens the accessibility of food and water, Thompson said.
Patients who are older, don’t speak English, and don’t have a high school education are more likely to experience harm during a hospital stay in Canada, according to new research.
The Canadian Institute for Health Information measured preventableharmful events from 2023 to 2024, such as bed sores and medication errors,experienced by patients who received acute care in hospital.
The research published Thursday shows patients who don’t speak English or French are 30 per cent more likely to experience harm. Patients without a high school education are 20 per cent more likely to endure harm compared to those with higher education levels.
The report also found that patients 85 and older are five times more likely to experience harm during a hospital stay compared to those under 20.
“The goal of this report is to get folks thinking about equity as being a key dimension of the patient safety effort within a hospital,” says Dana Riley, an author of the report and a program lead on CIHI’s population health team.
When a health-care provider and a patient don’t speak the same language, that can result in the administration of a wrong test or procedure, research shows. Similarly, Riley says a lower level of education is associated with a lower level of health literacy, which can result in increased vulnerability to communication errors.
“It’s fairly costly to the patient and it’s costly to the system,” says Riley, noting the average hospital stay for a patient who experiences harm is four times more expensive than the cost of a hospital stay without a harmful event – $42,558 compared to $9,072.
“I think there are a variety of different reasons why we might start to think about patient safety, think about equity, as key interconnected dimensions of health-care quality,” says Riley.
The analysis doesn’t include data on racialized patients because Riley says pan-Canadian data was not available for their research. Data from Quebec and some mental health patients was also excluded due to differences in data collection.
Efforts to reduce patient injuries at one Ontario hospital network appears to have resulted in less harm. Patient falls at Mackenzie Health causing injury are down 40 per cent, pressure injuries have decreased 51 per cent, and central line-associated bloodstream infections, such as IV therapy, have been reduced 34 per cent.
The hospital created a “zero harm” plan in 2019 to reduce errors after a hospital survey revealed low safety scores. They integrated principles used in aviation and nuclear industries, which prioritize safety in complex high-risk environments.
“The premise is first driven by a cultural shift where people feel comfortable actually calling out these events,” says Mackenzie Health President and Chief Executive Officer Altaf Stationwala.
They introduced harm reduction training and daily meetings to discuss risks in the hospital. Mackenzie partnered with virtual interpreters that speak 240 languages and understand medical jargon. Geriatric care nurses serve the nearly 70 per cent of patients over the age of 75, and staff are encouraged to communicate as frequently as possible, and in plain language, says Stationwala.
“What we do in health care is we take control away from patients and families, and what we know is we need to empower patients and families and that ultimately results in better health care.”
This report by The Canadian Press was first published Oct. 17, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
CALGARY – Alberta’s health minister says a new agency responsible for primary health care should be up and running by next month.
Adriana LaGrange says Primary Care Alberta will work to improve Albertans’ access to primary care providers like family doctors or nurse practitioners, create new models of primary care and increase access to after-hours care through virtual means.
Her announcement comes as the provincial government continues to divide Alberta Health Services into four new agencies.
LaGrange says Alberta Health Services hasn’t been able to focus on primary health care, and has been missing system oversight.
The Alberta government’s dismantling of the health agency is expected to include two more organizations responsible for hospital care and continuing care.
Another new agency, Recovery Alberta, recently took over the mental health and addictions portfolio of Alberta Health Services.
This report by The Canadian Press was first published Oct. 15, 2024.
Rana Van Tuyl was about 12 weeks pregnant when she got devastating news at her ultrasound appointment in December 2020.
Her fetus’s heartbeat had stopped.
“We were both shattered,” says Van Tuyl, who lives in Nanaimo, B.C., with her partner. Her doctor said she could surgically or medically pass the pregnancy and she chose the medical option, a combination of two drugs taken at home.
“That was the last I heard from our maternity physician, with no further followup,” she says.
But complications followed. She bled for a month and required a surgical procedure to remove pregnancy tissue her body had retained.
Looking back, Van Tuyl says she wishes she had followup care and mental health support as the couple grieved.
Her story is not an anomaly. Miscarriages affect one in five pregnancies in Canada, yet there is often a disconnect between the medical view of early pregnancy loss as something that is easily managed and the reality of the patients’ own traumatizing experiences, according to a paper published Tuesday in the Canadian Medical Association Journal.
An accompanying editorial says it’s time to invest in early pregnancy assessment clinics that can provide proper care during and after a miscarriage, which can have devastating effects.
The editorial and a review of medical literature on early pregnancy loss say patients seeking help in emergency departments often receive “suboptimal” care. Non-critical miscarriage cases drop to the bottom of the triage list, resulting in longer wait times that make patients feel like they are “wasting” health-care providers’ time. Many of those patients are discharged without a followup plan, the editorial says.
But not all miscarriages need to be treated in the emergency room, says Dr. Modupe Tunde-Byass, one of the authors of the literature review and an obstetrician/gynecologist at Toronto’s North York General Hospital.
She says patients should be referred to early pregnancy assessment clinics, which provide compassionate care that accounts for the psychological impact of pregnancy loss – including grief, guilt, anxiety and post-traumatic stress.
But while North York General Hospital and a patchwork of other health-care providers in the country have clinics dedicated to miscarriage care, Tunde-Byass says that’s not widely adopted – and it should be.
She’s been thinking about this gap in the Canadian health-care system for a long time, ever since her medical training almost four decades ago in the United Kingdom, where she says early pregnancy assessment centres are common.
“One of the things that we did at North York was to have a clinic to provide care for our patients, and also to try to bridge that gap,” says Tunde-Byass.
Provincial agency Health Quality Ontario acknowledged in 2019 the need for these services in a list of ways to better manage early pregnancy complications and loss.
“Five years on, little if any progress has been made toward achieving this goal,” Dr. Catherine Varner, an emergency physician, wrote in the CMAJ editorial. “Early pregnancy assessment services remain a pipe dream for many, especially in rural Canada.”
The quality standard released in Ontario did, however, prompt a registered nurse to apply for funding to open an early pregnancy assessment clinic at St. Joseph’s Healthcare Hamilton in 2021.
Jessica Desjardins says that after taking patient referrals from the hospital’s emergency room, the team quickly realized that they would need a bigger space and more people to provide care. The clinic now operates five days a week.
“We’ve been often hearing from our patients that early pregnancy loss and experiencing early pregnancy complications is a really confusing, overwhelming, isolating time for them, and (it) often felt really difficult to know where to go for care and where to get comprehensive, well-rounded care,” she says.
At the Hamilton clinic, Desjardins says patients are brought into a quiet area to talk and make decisions with providers – “not only (from) a physical perspective, but also keeping in mind the psychosocial piece that comes along with loss and the grief that’s a piece of that.”
Ashley Hilliard says attending an early pregnancy assessment clinic at The Ottawa Hospital was the “best case scenario” after the worst case scenario.
In 2020, she was about eight weeks pregnant when her fetus died and she hemorrhaged after taking medication to pass the pregnancy at home.
Shortly after Hilliard was rushed to the emergency room, she was assigned an OB-GYN at an early pregnancy assessment clinic who directed and monitored her care, calling her with blood test results and sending her for ultrasounds when bleeding and cramping persisted.
“That was super helpful to have somebody to go through just that, somebody who does this all the time,” says Hilliard.
“It was really validating.”
This report by The Canadian Press was first published Oct. 15, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
