The Northwest Territories will begin offering booster shots against Covid-19 to residents as young as 50, a local decision that outpaces the speed at which national guidance is evolving.
So far, the national body that issues vaccination advice only recommends a booster dose for long-term care residents and an extra full dose for immunocompromised people. There is “currently no evidence” anyone else needs a booster, the National Advisory Committee on Immunization states.
Dr Kami Kandola, the NWT’s chief public health officer, says otherwise. Dr Kandola says the NWT began vaccinating its residents so early, compared to the rest of Canada, that she does now have evidence warranting the introduction of a booster shot for many more people.
As a result, the NWT on Friday began offering booster doses of Covid-19 vaccine to any Yellowknife residents aged 60 and over.
From next week, that program will expand. Booster shots will be available to anyone aged 60 and over in Yellowknife, Ndilǫ, Dettah, Hay River, Inuvik, and Fort Smith, and anyone aged 50 and over in smaller NWT communities. (The NWT’s health authority asked eligible residents to book online in Yellowknife or contact their local health centre or public health unit elsewhere. There are full details on the health authority’s website.)
“Sometimes I have to look at my own data, look at our own unique circumstances, and realize we are eight to 12 weeks ahead of where Canada will be,” Kandola told Cabin Radio on Friday.
“We gave the vaccines early, we gave them in a tight schedule. Our breakthrough cases are higher, our breakthrough severe outcomes are higher.
“The vaccine is still protective but we need to focus on who, if they get Covid, would end up with severe outcomes. Right now, it’s 60 and older in the four hubs and 50 and older in the smaller communities.”
The NWT issued its opening doses of vaccine on December 31, 2020, weeks ahead of almost anywhere else in Canada. Kandola says that means the territory is dealing with circumstances the national advisory body has yet to fully consider.
She is instead drawing lessons from countries like Israel that followed a similarly speedy vaccination timeline.
Meanwhile, Kandola says her own data shows the vaccines work – but don’t appear to be giving NWT residents the level of protection national guidance expects.
“The NWT has been looking very keenly at what’s happening in Israel and the UK, and we’ve looked at our own data. Right now, the vaccine is protective against developing Covid, transmitting Covid, and severe outcomes, but the magnitude is smaller than what the national picture is showing,” said Kandola.
“The national picture would state that you’re 10 times more likely to be infected if you’re unvaccinated versus fully vaccinated. What we’re seeing is protection among the fully vaccinated, but the magnitude is two-and-a-half to three times instead of 10. The national picture says you’re 36 times less likely to be hospitalized, but we’re seeing a smaller magnitude.
“When we see that decrease in magnitude, we’re looking at specifically a high-risk population. This is from my own direction: we are going ahead and providing a booster to everyone 60 and older in the regional hubs, and in the small communities – because of a lack of healthcare access – we are providing a booster to everyone 50 and older. We will be the first in Canada to do this.”
Boosters for everyone?
Kandola on Friday would not be drawn on whether, and how soon, a booster dose would be expanded to all eligible NWT residents. Equally, she did not rule it out.
“Let’s start with the high-risk population,” she said.
“We are going to be monitoring the rates on a weekly basis. Right now, the vaccine is still protective. Israel saw the biggest impact in people aged 60 and older with the booster program, even though they provided the booster to the whole population 12 and older.”
Nevertheless, NWT health minister Julie Green made a much clearer commitment to a broad booster-dose rollout during a nationally televised interview last week.
Speaking with the CBC’s Rosemary Barton on October 10, Green said: “We’ll work our way through the rest of the population, as we did with the initial vaccines.”
Green noted the territory had already begun offering full third doses to front-line workers.
“There’s a good portion of our population who’ve been vaccinated eight or nine months ago and we are finding their immunity is waning,” the minister told Barton.
“They need booster shots, which we have started to administer, not only to Elders but to people who are front-line workers and immunocompromised.”
The NWT is not totally alone in expanding booster availability beyond national guidelines, though no other Canadian jurisdiction has yet expanded availability as far.
Alberta is offering boosters to residents aged 75 and over. Manitoba has made boosters available to healthcare workers.
In general, though, scientists have to date concluded it’s too early for booster shots among the general public.
A new study from Toronto’s Institute for Clinical Evaluative Sciences, examining Ontario residents, states initial vaccine protection against infection and severe outcomes remained strong eight months after vaccination. The study has yet to be published but was presented to some doctors and scientists last week, The Globe and Mail reports.
Yet Kandola argues the NWT is well past that point for many residents and she needs to be making decisions ahead of colleagues in other jurisdictions.
She used the recent outbreak of Covid-19 at Yellowknife’s Avens seniors’ facility as an example.
On August 19, Kandola directed that a full-dose booster – effectively a third shot – should be given to the territory’s long-term care residents. The national advisory committee did not issue a statement advising boosters in long-term care settings until September 28.
“That was also the week that we had an outbreak in Avens,” said Kandola.
“If I hadn’t provided that recommendation six weeks earlier, the Avens outbreak wouldn’t have gone as smoothly.”
Staff at Avens reported the outbreak was limited to four cases.
Scientific and ethical balance
The science of booster shots is complicated by the continual emergence of variant forms of the coronavirus that causes Covid-19.
Last week, Health Canada said it was evaluating data from vaccine manufacturer Moderna regarding a booster shot half the size of the first two doses.
To date, Moderna’s Spikevax appears to be one of the better-performing vaccines against the Delta variant that’s causing the current NWT outbreak. It’s also the vaccine most of the adult NWT population received.
Even so, manufacturers are actively working on next generations of their vaccines designed to specifically target newer, more dangerous variants.
The Delta variant is “just so good at infecting people and replicating that it raises the bar on how good vaccines have to be,” Moderna president Stephen Hoge said last month.
Public health officials must weigh current protection levels from the initial vaccine, the protection offered by a new dose of the same vaccine, and the possible protection to come from newer vaccines now in development – then find the right time to act.
At the moment, the source of the NWT’s vaccine stockpile for a booster campaign that reaches beyond national recommendations is not clear.
As of October 14, the federal government said the territory had received 72,870 doses of Spikevax and 9,360 doses of Pfizer-BioNTech’s Comirnaty vaccine, which the NWT has primarily used to vaccinate youth following its authorization among children aged 12 to 17.
That provides 82,000 doses for the NWT, which has roughly 38,000 residents aged 12 and over but which must also ensure doses are available if and when vaccines are approved for children younger than 12.
The federal government says its central vaccine inventory “continues to be managed strategically to best support both Canada’s evolving domestic needs and global vaccination efforts.”
Access to boosters, in other words, must be evaluated against a commitment to help the rest of the world receive even basic vaccination. Hundreds of millions of people still have no vaccine access at all, and companies like Moderna have been criticized for an approach that leaves poorer countries paying more and waiting longer for supplies.
In September, the World Health Organization urged nations to hold off on booster doses until at least the end of the year and prioritize vaccine delivery to remaining countries instead.
“I will not stay silent when the companies and countries that control the global supply of vaccines think the world’s poor should be satisfied with leftovers,” WHO Director-General Tedros Adhanom Ghebreyesus said at the time.