MONTREAL -- It’s been 42 days since residents of Maimonides Geriatric Centre in Montreal received their first doses of the Pfizer COVID-19 vaccine, and with no appointments scheduled to administer the second dose, Quebec is now heading into the “wilderness,” says a leading Montreal geriatrician.
Dr. Jose Morais, Chief of Geriatric Medicine at McGill University, emphasized that he thinks “these are difficult decisions,” and “from the public health standpoint, maximizing the distribution of the vaccine is the right thing to do,” to protect a larger number of vulnerable seniors and front-line health-care workers.
From what is known about vaccines and immunity, he also said it’s unlikely the protective effects of one dose will just abruptly disappear. They usually diminish more slowly, and it is possible the effects could last for three months.
But Quebec’s decision to delay the second dose up to 90 days so that double the number of vulnerable Quebecers can be immunized with a first vaccine is not risk-free, Morais said.
“We are in unknown territory. We may be taking undue risks for these particular people because the science supports giving it up to six weeks, 42 days, and the WHO (World Health Organization) has looked into this data and this is what they suggest,” the geriatric specialist said.
Benoit Masse, a public health researcher at Universite de Montreal agreed with the assessment made by Morais.
“Yes, there are potential risks with delaying the second dose beyond six weeks. Unknown risks,” he said.
Canada’s National Advisory Committee on Immunization (NACI) also recommended a six-week delay in a report issued on Jan. 12, because that specific waiting period between doses has been proven to work in clinical trials for Pfizer and Moderna vaccines.
It advised the strategy only be deployed in response to a perfect storm: a rising number of cases, strain on hospitals and a limited supply of vaccines.
In a Jan. 21 update on the province’s decision to delay second shots as long as 90 days, the Quebec Public Health Institute (INSPQ) noted in French, that “no maximum interval between doses is specified,” by the NACI and that “the proposal to not exceed 42 days is therefore not based on data of decreased efficacy after this time period.”
That means the decision to not exceed 42 days was also made by the NACI, because there is currently no data to back it up, as Morais and Masse explained.
Quebec’s immunization committee does conclude administering a second dose is necessary to assure long-term protection, and that the timing of the second dose could be advanced if studies eventually show efficacy wanes after the first dose.
FAMILIES IN LIMBO
As they mark day 42 on the calendar, family members of the long-term care residents at Maimonides remain in the dark about the timeline.
Joyce Shanks, whose father lives at the facility, said the families did not get a response “to the original legal action that we took.”
The Maimonides Family Advocacy Committee is accusing the government of breach of contract.
Lawyer Julius Grey sent an open letter to the premier and health minister more than two weeks ago.
Nor have they heard anything from the West-Central Montreal health authorities (CIUSSS) about the second dose, said Shanks.
“They are toeing the government line. We have nothing specific to go on about the vaccine,” she said, adding “we are exploring every legal opportunity.”
When CTV asked the West-Central Montreal CIUSSS if it has set a date for the second shot to be administered, a spokesperson directed us to Quebec’s health ministry. A Quebec health ministry spokesperson, in turn, invited us to “reach out to the West-Central Montreal CIUSSS with that question.”
But the government is likely recalculating its timeline for the umpteenth time now that most of the province’s doses have been administered - and because Pfizer has delayed shipments of its vaccines to Canada, it is putting public health officials in an even more precarious position.
That was confirmed Monday when the health ministry told CTV that because of the “important'' reduction in the number of Pfizer doses they had expected to receive over the next two weeks, they “must review the vaccination calendar, notably for the RPAs,” which are private seniors' residences.
Above all, the vaccine shortage and dosing strategy have now pushed Quebecers waiting for the booster shot well past the goal lines - three weeks past the vaccine manufacturer’s recommendations, and past the 42-day emergency interval laid out by the NACI.
CALCULATED RISKS
The decision to give the second dose any time past Pfizer’s 21-day schedule or Moderna’s 28-day recommendation has divided scientists and clinicians around the world, particularly in Canada and also in the U.K, where a 12-week dosing interval has also been approved.
“Even us, we are torn apart between these two scenarios,” revealed Morais, who works at two MUHC hospitals as well as the Jewish General Hospital.
“I have a colleague who decided to take no vaccination. He said if I didn’t receive the second dose within 42 days, why bother taking the first vaccination?” Morais said.
In an email exchange with CTV, public health expert Masse acknowledged that Quebec is walking a tightrope as he spelled out the province’s predicament.
“The benefit of delaying the second dose is (almost) immediate. We protect more people with a first dose, as we are in a large outbreak that we are barely able to control. We are talking about saving lives and hospitalizations in the short term,” he wrote.
Once immunity starts to kick in though and then builds - at 14 days after the first dose, according to a study in the New England Journal of Medicine - even some protection can mean the difference between a survivable illness and one that’s fatal.
However, if the risk turns out to be real - that the vaccine’s protective effects decline quickly or the effectiveness of the first dose turns out to be considerably weaker than expected - then Masse said we could “end up with no net gain overall or worse, an overall increase in death and hospitalizations.”
Masse argued, though, that it’s likely the intensity of the second wave will ease in the coming months and only if there is a rapid decline in the efficacy would we “undo all the benefits we can get right now by vaccinating the maximum number of people.”
Also, getting one dose of the vaccine, even two doses doesn’t mean anyone should stop following all recommended hygiene and distancing measures in the short-term. No one knows yet if the vaccines approved in Canada, will prevent transmission of the virus.
Finally, Masse offered the following assignment, suggesting people ask themselves what they’d do if they have two parents who are both 80 years old (as he does).
“If you give me two doses of a vaccine right now, what do I do? Vaccinate only my mother and keep the one dose in the freezer - or, vaccinate both my mother and father right now?”
In the current climate, when case numbers and community transmission are still high, “I choose the latter without hesitation. In the context of a huge outbreak, I want to protect both of them,” the public health researcher said.
