RNAO’s letter to the premier on the vaccine rollout and the current context

RNAO sent the following letter on February 10 to Premier Doug Ford and Minister of Health Christine Elliott to convey our thoughts and priorities regarding the rollout. We also expressed our concerns regarding the premature lifting of the lockdown.

Dear Premier Ford and Minister Elliott,  

As Ontario prepares to receive sizable supplies of the COVID‐19 vaccine, we are writing to convey our thoughts and priorities regarding the rollout. As you know, RNAO has been actively engaged in discussions with members of the nursing community and the public at large regarding this critical and hopeful moment in the pandemic.  

We are focusing on key aspects of the vaccine rollout that are essential to its success. These include: the need for transparent and detailed plans for the massive immunization campaign commencing in March; the need to engage public health and community providers as pillars of the rollout; the importance of giving priority to elderly Ontarians who are most likely to die from COVID‐19; and targeted efforts to vaccinate vulnerable populations that otherwise may be inoculated last, or not at all. We also urge you to ensure the vaccine rollout does not distract us from the life‐and‐death public health measures that must continue if we are to preempt a catastrophic third wave driven by new variants.  

Prepare for large‐scale immunization starting in March: This task, starting in about three weeks, will be significant. As of Feb. 9, Ontario
had administered about 400,000 doses. According to Prime Minister Trudeau, Canada will receive six million doses by the end of March. For Ontario, this translates into about 600,000 doses in February and 1.2 million in March. These numbers suggest that during March, Ontario should be administering about 40,000 doses per day, or about four times the current daily rate. The rate of immunization will scale up even more in April and beyond, when five million doses are expected in Ontario each month, or about 160,000 doses per day, until 
the campaign is over.  

The Ontario government has not provided transparent access to detailed plans on how it will tackle this challenging rollout. To be successful, our government should lay out those plans and actively seek feedback and participation from diverse experts and communities.  

Engage public health and community providers: As RNAO has indicated on various occasions (media releases on Jan. 12 and Jan 14), and as recently as last week, the successful rollout of Phase 2 should rely on thousands of nurses, physicians and pharmacists working in community care across this province. Every year, these skilled professionals provide routine vaccinations through public health and established networks, including primary care, pharmacies and home care. These community‐based infrastructures, and the health‐care professionals who make them work, use tried and true distribution systems for vaccination. They must be utilized fully to deliver what is urgently needed – COVID‐19 vaccinations – 24‐hours‐a‐day, seven‐days‐a‐week. 

Prioritize right: Focus on the elderly. The initial purpose of the vaccine rollout should be clear: Reduce – as much as possible – hospitalizations, ICU utilization and deaths from COVID‐19. This is both an ethical mandate and a practical necessity due to the state of critical care in this province.  

The key insight from science is clear: Age is a dominant variable. Patients who are 80 or older are at least 20 times more likely to die from COVID‐19 than those in their fifties. They are also hundreds of times more likely to die than those who are 40 or younger. Canadian data supports these findings. Ninety‐six per cent of those who died from COVID‐19 by Feb. 9 were 60 years or older, and 71.2 per cent of hospitalizations had been in that age range.  

It is questionable that “older adults, beginning with those 80 and older and decreasing in five‐year increments over the course of the vaccine rollout” were included in Phase 2 of the Ontario rollout plans rather than in Phase 1. According to Statistics Canada, there are about 655,000 Ontarians 80 and older, and if this number was too high to incorporate into Phase 1, at least the 336,000 who are 85 or older should have been included (these numbers include those in the age bracket who are residents in long‐term care and high‐risk retirement homes, who are part of the Phase 1 rollout). Given the decisions made, it is crucial that elderly Ontarians who were not inoculated in Phase 1 be at the top of the list in Phase 2.  

Despite the enormous risk for deadly outbreaks in long‐term care and high‐risk retirement homes, the government was late in prioritizing these congregate settings, although they are part of Phase 1. Fortunately, the long‐term care sector is now scheduled to receive its first dose of vaccine by Feb. 10.  

RNAO remains extremely concerned that elderly persons outside long‐term care settings do not appear to be at the front of the queue in Phase 2. They appear to be further back than health‐care workers who do not work on the frontlines, or even other essential workers who must be supported, but who are, on average, much less likely to die from COVID‐19. This must be corrected urgently and ahead of launching Phase 2.  

RNAO’s message to the provincial government is simple: Elderly Ontarians are most likely to be hospitalized, admitted to ICU and/or to die from COVID‐19. Rollout should start immediately with those 80 or older, with a continuous reduction in the eligible age down to 60 as the Phase 2 rollout progresses. Not only is this the right thing to do, but it will also contribute to diminishing the pressure on critical care in our province.  

Prioritize right: Target vulnerable populations. The experience of COVID‐19 immunization in the United States suggests that young, white and wealthy, more tech‐savvy people often end up snagging online appointments, even though they are least impacted by COVID‐19. Racialized, marginalized, low‐income and elderly populations, in contrast, face challenges accessing appointments.  

Studies identify older people, men, racial and ethnic minorities, and those with underlying health conditions among the most vulnerable populations that are more likely to die of COVID‐19. These groups have higher levels of co‐morbidities and face higher rates of hospitalization and death due to the virus.  

There are many reasons people may face difficulty or hesitancy getting the vaccine. Persons in disadvantaged social groups may encounter language barriers, misinformation, lack of access to technology, difficulties using online appointment software, historical injustices, mistrust of government and medical institutions, mobility restrictions, financial constraints, employment concerns (i.e. missing a day of work to get vaccinated), and so on. These multiple barriers are not mutually exclusive, and are often exacerbated by one another.  

All of these barriers must be squarely addressed early in Phase 2. Targeted plans for each community need to fit the needs of that community. This is the only way vulnerable populations will get the priority they require in vaccine rollout. The plans should be developed with leading involvement and the participation of members of the communities affected, as that’s the only way to succeed.   

Do not allow vaccines to distract us from a potentially devastating third wave. Israel has been a learning ground for the successful deployment of mass vaccination. But it has also shown us that vaccines are not a silver bullet. With more than 50 per cent of the population inoculated, the country is still in lockdown. Its hospitals and ICUs are still at capacity. A leading Israeli health officer has noted that the introduction of the British strain has been a negative game changer for Israel. The vaccines have been a big success, but they are not enough to curb the rise in contagion brought by the mutation. Hospital beds left free by the inoculated over‐60 population are being filled by the under‐50 crowd. “The danger confronts any country that chooses a primarily vaccine‐reliant policy before COVID‐19 is finally vanquished.” 

This is a crucial lesson for Ontario as the B117 variant, first identified in the United Kingdom and the one creating havoc in Israel, will likely become the dominant strain in Ontario within four to six weeks. There is the distinct risk of an explosive rise in the number of cases and hospitalizations. The public is not prepared for the worrisome characteristics of some of these variants, which appear to challenge our assumptions about transmissibility (such as two‐metre distancing, 15 minutes of exposure, and use of regular cloth masks).  

RNAO has pleaded with the government not to open up parts of the province before ensuring the necessary public health measures are in place to safeguard the lives and livelihoods of Ontarians and to control the spread of COVID‐19.  

What do we do now? It is essential to wait before loosening restrictions. We need at least three weeks after schools re‐open in a specific region to make sure epidemiological data is moving in the right direction. It is also important to restrict travel between regions with different levels of measures. Contact tracing and isolation must continue to be strengthened across the province to handle the existing number of infections. And there must be stronger plans to upgrade public health measures and make sure they are strictly enforced in workplaces.  

RNAO also urges the government to immediately act to protect vulnerable communities. We have repeatedly called on you, Premier Ford, to cover paid sick days to protect workers who do not have access to them as part of their employment, and for whom the federal benefit does not suffice. RNAO has also demanded that the government enact a full moratorium on evictions and provide places for people to self‐isolate safely while awaiting test results. 

While we understand that businesses are hurting, opening up too soon carries an inherent risk that affects everyone in this province, especially those most vulnerable, and who have assumed the greatest burden of this relentless virus. It is the responsibility of governments to provide proper economic supports for businesses closed or suffering due to public health measures. 

All of these factors must be considered in the Ontario government’s plan to begin re‐opening the economy. The focus for the government should be to ensure a successful rollout of vaccines, as detailed above, while maintaining public health measures and engaging the public so we can all get through this together.  

With warm regards, and best wishes for health and safety, 

Doris Grinspun (RNAO Chief Executive Officer) and Morgan Hoffarth (RNAO President)