The Problems with Ontario's Vaccine Rollout

Opinion by Chanel Best. This piece is part of The Global Vaccine Challenge, a series by Chanel Best on the inequalities in access and distribution of COVID-19 vaccines.

Failure by the Ontario government to adopt the recommendations of public health officials has eroded public trust since the beginning of the pandemic. One of the most contentious debates during the rollout has been about who should be able to access vaccines first. The Ford government chose to allow access to vaccines based on age, job title and postal code, which sounds sensible in theory, but in practice, the administration of vaccines was uneven and ineffective across the province. Despite having guidance from The Science Table COVID-19 Advisory for Ontario and The National Advisory Committee on Immunization (NACI), the provinces rollout did not prioritize those who had the most risk of contracting and spreading COVID-19. Key failures of Ontario’s vaccination campaign consist of not including strategies to vaccinate Ontarians with mobility issues, using age as the dominate criteria when administering vaccines, and disparity in relation to hotspots. By not adapting to scientific data at all stages of the campaign Doug Ford created unnecessary barriers to vaccine access.

Mobility Challenges

The main method for booking vaccines is through the provincial online portal. The system was created to ensure that every person in the province would have equal access to vaccines, however immediate issues arose for those with mobility challenges [1]. In 2020, 76,755 or around 1.1 per cent of Ontarians aged 65 and over were considered homebound and as of March 29, 2021, 303,552 or 26.4 per cent of residents 75 years or over have not received or registered for a first dose of a COVID-19 vaccine through the provincial booking system [2]. While the Ontario COVID-19 vaccination information website has an online phone booking tool for those who require special assistance, it does not provide a viable solution for those with mobility challenges who need to receive their vaccine from their home.

Without a provincial-wide strategy to vaccinate people with mobility issues, it became the duty of municipal governments to solve this issue despite having less resources to do so. The City of Toronto partnered with Toronto Public Health and other local primary care teams to implement a plan to vaccinate residents with mobility issues. The campaign successfully increased vaccinations among those 80 and older through door-to-door mobile vaccine clinics [3]. However, Toronto is one of the few cities in Ontario that has the resources available to fill the gaps in the provincial rollout. Health units in mid-size cities, rural communities, and northern Ontario are smaller than those in the GTA and rely more on the provincial health system. Therefore, except for those living in Toronto or other municipalities that have implemented a framework for those that are homebound, residents with mobility challenges have been excluded from Ontario's vaccination rollout.

Risk-Based Administration

NACI released recommendations for provincial vaccination programs, which suggested those with the highest risk of severe illness or death due to COVID-19 should be prioritized. The first set of recommendations stated the need for an equitable approach that prioritized:

1. Those at elevated risk from complicated illness or death due to COVID-19, such as elderly residents.

2. Those most likely to transmit COVID-19 to those at elevated risk & essential workers in maintaining the pandemic response, such as those working in long term care including administrative staff.

3. Those working in other essential areas required for the functioning of society, such as those who cannot work from home.

4. Those who may face conditions that increase their risk or in places where contracting COVID-19 could have disproportionate consequences, such as remote Indigenous communities [4].

In Ontario, stage one of the vaccination rollout, which began in December, allowed healthcare workers and citizens aged 80 and over to receive a vaccine. This perfectly followed NACI’s recommendations as elderly persons face a greater risk due to their age and propensity to have pre-existing conditions, and essential healthcare workers are exposed to the virus.

The first failure occurred when the government began to prioritize those aged 55+ before those who had the greatest chance of spreading the virus. Those aged 55 and over are more likely to work from home and have a low chance of contracting or spreading COVID-19, whereas those under the age of 35 are more likely to be working in public or socializing [5]. This age group is also more likely to work in industries that remain open such as the food and grocery sectors. Not allowing access to workers who remained in public meant that many young people were risking their lives working minimum wage jobs without the protection of the vaccine. After the vaccination campaign began the in Ontario, there was a shift in the dynamics of viral transmission. When the B.1.1.7 COVID-19 variant began spreading, a correlation began to emerge between low vaccination rates in younger age cohorts and increased community transmission amongst young people [6]. Data provided by the province in March indicated that the 53.4 per cent of cases were now made up of young people aged 39 and under [7]. However, the province did not open vaccinations to that age group until May 18, 2020. Prioritizing vaccinating the groups who had the highest case rates could have curbed the devastation of the third wave.

Hot Spots Not Spots

In February, the Ontario Science Advisory Table noted that certain postal codes had significantly higher case rates of COVID-19 than others [10]. In April, the provincial government declared it would begin allowing vaccinations for those in neighbourhoods with higher case rates. The government announced that all adults residing in 114 postal codes across the province would be eligible for a vaccine. [11] Based on available data, Ontario gave priority access to some neighbourhoods that had been less affected than others, but some of the postal codes declared as hotspots had transmission rates significantly lower than the provincial average. A review of the data by CBC found that Ottawa postal code K2V in Kanata had a hospitalization and death rate of 0.35 per 1000, lower than the rate of postal codes not designated as hot spots. The same data also revealed seven postal codes that were left out of the hotspot designation but had higher rates of transmission than the provincial average [12].

While the provincial government eventually moved to prioritize these hot spots in the vaccination effort, the vaccination strategy did not stay true to recommendations by the advisory table which suggested a vaccine distribution strategy that prioritizes individuals based on both their age and neighbourhood of residence. This approach could have reduced cases of COVID-19 infection, hospitalizations, ICU admissions, and deaths due to the virus. Data from the Science advisory table noted that if the province allocated 50 per cent of the vaccine supply to the top 20 per cent of hot spot neighbourhoods it could drastically improve control of the spread of COVID-19 based on Ontario administering around 100,000 vaccines a day [13].

Conclusion

As soon as data surrounding mobility concerns, community spread among younger age cohorts, and hot spots were available, the government should have been pushed to adapt their strategy and consider a more effective approach to vaccine distribution. The challenges the province faced in the third wave could have been avoided with the vaccines available, but they were not being allocated properly based on scientific data. The government failed to ensure that Ontario’s rollout could efficiently provide vaccine access to those who had the greatest chance of spreading the virus. Vulnerable groups were left out of the rollout, demonstrating that an inequitable response was also an ineffective one. By failing to adhere to the data-driven recommendations of the public health advisors, Doug Ford undoubtedly prolonged and exacerbated the damage of COVID-19.

Figure 1 (above) summarizes NACI's interim recommendations on key populations for early COVID-19 immunization for public health program level decision-making. Government of Canada, Preliminary guidance on key populations for early COVID-19 immunization, https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/guidance-key-populations-early-covid-19-immunization.html.

Figure 2 (left) depicts the age demographics of COVID-19 patients. Government of Ontario. All Ontario: Case numbers and spread, 2021. https://covid-19.ontario.ca/data

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Bibliography

1. Science Table COVID-19 Advisory for Ontario. Mobile In-Home COVID-19 Vaccination of Ontario Homebound Older Adults by Neighbourhood Risk, Health Equity & Social Determinants of Health. V1.0, 31 March 2021. Science Table. https://covid19-sciencetable.ca/sciencebrief/mobile-in-home-covid-19-vaccination-of-ontario-homebound-older-adults-by-neighbourhood-risk/

2. Science Table COVID-19 Advisory for Ontario, March 2021.

3. Science Table COVID-19 Advisory for Ontario, March 2021.

4. Government of Canada. Preliminary guidance on key populations for early COVID-19 immunization, 13 November 2020. https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/guidance-key-populations-early-covid-19-immunization.html

5. Science Table COVID-19 Advisory for Ontario. A Strategy for the Mass Distribution of COVID-19 Vaccines in Ontario Based on Age and Neighbourhood, Health Equity & Social Determinants of Health. V1.1, 26 February 2021. https://doi.org/10.47326/ocsat.2021.02.10.1.0

6. Science Table COVID-19 Advisory for Ontario, Feb 2021.

7. Government of Ontario. All Ontario: Case numbers and spread, 2021. https://covid-19.ontario.ca/data

8. Science Table COVID-19 Advisory for Ontario, Feb 2021.

9. Crawley, M. These 'hot spots' getting vaccine priority are less hard-hit by COVID-19 than Ontario average, CBC News. 12 April 2021. https://www.cbc.ca/news/canada/toronto/ontario-covid-19-vaccination-postal-code-hot-spots-1.5983155#Hard%20hit%20postal%20codes%20without%20hotspot%20status

10. Crawley, M. April 2021.

11. Science Table COVID-19 Advisory for Ontario, Feb 2021.