Dear Colleagues: Welcome to our Saturday, June 12 report during this sixteenth month of COVID-19 in Ontario. You can find earlier update reports here, including thematic pieces in Doris’ COVID-19 Blog. And, for the many resources RNAO offers on COVID-19, please visit the COVID-19 Portal where you will also find RNAO media hits and releases on the pandemic here. Daily Situational Reports from Ontario's MOH EOC can be found here. As always, feel free to share this report and links with anyone interested. Scroll down for information on an upcoming webinar.
the time interval for second dose after first AstraZeneca dose; and (7) celebrating Pride month
Reminder to answer our survey on nurses’ wellbeing (for RNAO members and non-members)
VOTE, VOTE, VOTE! (for RNAO members – Vote NOW)
RNAO members play an important role in deciding governance issues that affect the current and future direction of your professional association. One member, one vote is how you can make your voice heard. All regular members with the exception of undergraduate students are eligible to vote.
This year, members are asked to cast their vote on three items:
To learn more about the items and to vote go to https://myrnao.ca/rnao_election
Meet the Candidates Webinars:
Join us for a chance to speak with the President-Elect and Region 1 & 3 Candidates next week. Register here and be sure to include your questions on the registration form!
Archived webinars can be viewed here.
Voting opens on June 8th at noon and closes on June 24 at noon (ET). Results will be announced at the annual general meeting on June 25, 2021.
RNAO AGM getting close – June 24-26!
We are delighted to invite all RNAO members, other health professionals, and members of the public to our 96th Annual General Meeting (AGM) taking place on June 24 – 26, 2021. The theme for this year’s AGM is Protecting Ontarians and Leading Change: Nurses and RNAO during COVID-19.
The AGM will highlight the incredible leadership played by RNs, NPs and students in nursing Ontarians during the pandemic, and the role of RNAO and its members advocating for healthy public policies to protect nurses and the public. We have an exciting program of events that will be livestreamed to rnao.ca, Facebook, and YouTube.
If you have yet to register, be sure to not miss this awesome event. Register now!
We have an exciting three day program:
Thursday, June 24th
Opening Ceremonies | 6:00 p.m. – 7:30 p.m.
The opening ceremony is the official kick-off of our AGM. You’ll hear from Ontario’s top political leaders, government officials, and our international nursing colleagues. To top off the evening, we’ll be celebrating our newly designated provincial and international Best Practice Spotlight Organizations (BPSO).
Friday, June 25th
Annual General Meeting | 4:00 p.m. – 7:30 p.m.
The AGM is a time for members and the board of directors to gather to discuss the required business of the association:
Come and join us on the discussion!
Saturday, June 26th
Promoting 2SLGBTQI+ Health Equity Best Practice Guideline: Launch & Media Conference
10:45 – 11:15 a.m.
RNAO is excited to release its newest Best Practice Guideline (BPG), Promoting 2SLGBTQI+ Health Equity at this year’s Annual General Meeting (AGM).
The virtual release will celebrate the rigorous and collaborative efforts by RNAO and a diverse expert panel – consisting of persons with lived experience, activists, nurses and other health providers, researchers, educators and administrators – to publish a much-needed resource with evidence-based recommendations on ways to promote inclusivity and enhance the safety of 2SLGBTQI+ people across health, school and academic settings.
The virtual release will be hosted by RNAO President Morgan Hoffarth and will include the co-chairs of the BPG, Sheena Howard, RN, and past president of RNAO’s Primary Care Nurses of Ontario Interest Group, and Dr. Elizabeth Saewyc, RN and director of the School of Nursing at the University of British Columbia. Dr. Paul-Andre Gauthier, RN and provincial president of RNAO’s Rainbow Nurses’ Interest Group, will also take part as we release a related position statement. Speakers will discuss the important need for this BPG, its purpose and scope, share best practice recommendations, and answer questions from members of the media.
Closing Keynote: Protecting Ontarians and leading change: The COVID-19 pandemic as viewed through the eyes and experiences of RNs, NPs and nursing students.
12:00 p.m. – 1:30 p.m.
Concluding the exciting activities is our closing keynote presentation. Moderated by CEO Dr. Doris Grinspun, this presentation will include a panel of RNs, NPs and nursing students in all roles and sectors sharing their experiences working on the frontlines of COVID-19.
We look forward to your participation as we celebrate the past year’s achievements.
AstraZeneca second dose: Should I get the same vaccine or choose Pfizer or Moderna?
Ontarians have received about 900,000 doses of the AstraZeneca vaccine, mostly as a first dose. These Ontarians now have the choice of getting a second dose of the AstraZeneca or an mRNA vaccine. The following article, addressing the question of which one they should choose, is from Alexander Wong, an associate professor of infectious diseases at the University of Saskatchewan. It is republished from The Conversation under a Creative Commons license. The article summarizes the evidence on mixing and matching vaccines, as well as the safety profile of the AstraZeneca vaccine. Read the original article.
People in Canada whose first dose of COVID-19 vaccine was AstraZeneca have a choice to make: They can either choose one of the mRNA vaccines (Pfizer or Moderna) or another dose of AstraZeneca for their second shot.
The saga of AstraZeneca’s COVID-19 vaccine has been complicated. Clinical trials and real-world data from the United Kingdom have demonstrated its superb efficacy against severe illness and hospitalizations due to COVID-19.
In March, as much of non-Atlantic Canada experienced a surge of COVID-19 cases driven by the alpha (B.1.1.7) variant, reports from the European Union confirmed an association between AstraZeneca vaccine and rare but potentially fatal blood clots termed “vaccine induced thrombotic thrombocytopenia,” or VITT.
On March 31, given an unfavourable risk-benefit balance in younger people from the association with VITT, the National Advisory Committee on Immunization (NACI) recommended suspending the use of AstraZeneca in all people under age 55 in Canada. On April 23, as critically ill patients strained many hospital systems, NACI relaxed its guidance on AstraZeneca vaccine to allow its use in people over age 30 to speed up first dose uptake across Canada.
Finally, on May 11, Alberta and Ontario announced they would discontinue the use of AstraZeneca for first doses, citing uncertain supply of AstraZeneca vaccine and the evolving risk of VITT in Canada (1 in 55,000). Other provinces and territories quickly followed suit.
On June 1, NACI released additional guidance suggesting that people who received a first dose of AstraZeneca could receive either a second dose of AstraZeneca or a second dose of an mRNA vaccine. Provinces quickly amended their guidelines to allow recipients of AstraZeneca vaccine to choose their second dose of vaccine for themselves.
So the question of the moment is: What do I choose for my second dose if I’ve received a first dose of AstraZeneca?
Evidence for mixing and matching vaccines
Let’s begin with the evidence we have so far around mixing and matching vaccines, specifically AstraZeneca and Pfizer/BioNtech (Pfizer). On May 12, initial data on reactogenicity (the ability to produce common side-effects) data from the COM-CoV study in the United Kingdom was released. It included 830 people ages 50 and older, who were randomized into four study arms that received different combinations of AstraZeneca and Pfizer vaccines at four-week dosing intervals.
Participants who received different vaccines for their first and second doses, regardless of sequence of vaccination, had more side-effects (non-serious ones that resolved on their own) than those who received the same vaccine twice. No safety concerns were noted.
Experts theorized that the greater number of side-effects might predict a more robust immune response, but immunogenicity (the ability of the vaccine to provoke an antibody response) data is still pending and expected later this month.
Results from the Spanish CombiVacS study were reported on May 18. The study randomized 663 people who received AstraZeneca as their first dose to either receive Pfizer as a second dose booster eight weeks later, or into a control group with no second dose at all.
Those who received AstraZeneca followed by Pfizer developed twice as many antibodies as historically seen in people who received two doses of AstraZeneca alone. No safety concerns were identified.
A recent study from Germany released June 1 as a non peer-reviewed preprint adds additional information around mixing and matching AstraZeneca and Pfizer vaccines. This preliminary data included 26 individuals, ages 25 to 46, who were administered AstraZeneca as their first dose of vaccine, followed by a second dose of Pfizer given eight weeks later.
Neutralizing activity was 3.9 times greater against the alpha (B.1.1.7) variant and similar against the delta (B.1.617.2) variant compared to neutralizing activity seen in people who received two doses of Pfizer vaccine. No safety concerns were noted.
Lastly, a small Canadian study from Dalhousie University took two volunteers aged 66 and administered a first dose of AstraZeneca vaccine followed by a second dose of Pfizer vaccine 33 days later in both. The antibody responses were reported as being strong, with no safety concerns.
VITT risk with a second dose of AstraZeneca
The risk of VITT with a second dose of AstraZeneca for those who have received a first dose of AstraZeneca is very low. The best data currently available is surveillance data from the United Kingdom. As of May 27, 17 cases of VITT had been reported after 10.7 million second doses of AstraZeneca vaccine, for a risk of about 1 in 600,000.
Vaccine supply and availability
First doses of AstraZeneca vaccine were paused in Canada partly due to concerns with supply. However, a shipment of about 655,000 doses of AstraZeneca vaccine arrived in Canada in mid-May from COVAX, the global vaccine sharing initiative. It has been distributed now to provinces for use as second doses for persons who received a first dose of AstraZeneca.
The current and anticipated availability of both mRNA vaccines in Canada is excellent, with ongoing anticipated shipments throughout all of June and July. This means there will be no need to wait for one’s preferred option in most cases.
So what’s the best choice?
I was fortunate to receive two doses of COVID-19 vaccine in early 2021, so I don’t have to make a decision for myself. However, I’ve had many people ask me for advice on this subject on behalf of loved ones, friends and themselves.
While the data isn’t definitive, evidence is mounting to support a mixing and matching approach with AstraZeneca followed by Pfizer being at least as good (if not better) than giving two doses of the same vaccine. There is no inherent risk of mixing vaccines, and no safety concerns have been noted thus far.
Additionally, by taking an mRNA vaccine, one avoids the risk of VITT altogether. Even though this risk is very low, VITT is serious and potentially fatal.
For those reasons, my opinion is that if it’s accessible, a second dose of mRNA vaccine (either Pfizer or Moderna) is preferred for most people in Canada who have received a first dose of AstraZeneca.
The mRNA vaccines are anticipated to be widely available throughout June and July, when most Canadians will be lining up for second doses, so availability will not be a concern for either option.
The case for AstraZeneca
There are many reasons why one might choose AstraZeneca over an mRNA vaccine for their second dose. There is no clinical efficacy data for mixing and matching vaccines, such as clinical trials or real-world studies. For this reason, some may prefer a “proven” approach of receiving two doses of AstraZeneca. Some people who did not experience any adverse effects with their first dose of AstraZeneca may opt for a second dose of the same to try to avoid side-effects.
The COM-CoV study from the United Kingdom will report data on immunogenicity (antibody response) later this month. It may or may not be supportive of a mixing and matching approach. Some may prefer to wait for this data before deciding. Others may just be happy to take whatever vaccine is available and offered to them first.
Regardless of one’s decision, the critical point is for everyone to get a second dose as soon as they are eligible, whether it be AstraZeneca or an mRNA vaccine. The available evidence gives confidence that both options are safe and efficacious, so there’s no “wrong” choice here. Being fully vaccinated provides optimal protection against current and emerging strains, including the delta variant.
We are very fortunate in Canada to have the privilege to choose between two excellent options for our second doses. We have a responsibility to ensure that any unused vaccine supply is not wasted, and we must do much more to support global vaccine equity to help put an end the COVID-19 pandemic worldwide.
Reducing the time interval for second dose after first AstraZeneca dose
One question not addressed in the article above by Dr. Alexander Wong is the dosing interval between the first AstraZeneca (AZ) vaccine, and the second dose (whether AZ or mRNA). This is a topical question, which I address in the commentary that follows.
On May 28, the Ontario government announced that it was accelerating the rollout of second doses, but it was keeping the earlier established 12-week required interval between the first and second dose for persons who got AZ. On June 3 the announcement came that those who received a first dose of AZ can choose to either receive a second dose of AZ, or an mRNA (Pfizer or Moderna) vaccine for their second one. However, the dosing interval was kept at 12 weeks, no matter which choice the person made regarding the second dose.
Maintaining such a long dosing interval after a first dose of AZ has raised criticism, including from us at RNAO. Such guidance contrasts sharply with the shortened interval for those who received a first dose of mRNA, creating what appears to be a substantial inequity between the two groups. But beyond the apparent inequity, there is a real concern with such a delay.
The National Advisory Committee on Immunization (NACI) has recommended the interchangeability of AZ or mRNA second dose following the first AZ dose. They cite a UK study where an mRNA vaccine was given 4 weeks after the initial dose, a similar study in Spain that adopted an 8-week dosing interval, and one in Germany that adopted a 12-week interval. NACI summarizes: “Emerging evidence indicates that mixed COVID-19 schedules have an acceptable safety profile, which has been demonstrated at multiple dosing intervals between 4 and 12 weeks.”
Although the daily case numbers are gradually dropping in Ontario, the Delta variant (B.1.617, first discovered in India) is taking hold and becoming the dominant one, particularly in hotspots such as Peel, Toronto, York, Halton and Waterloo. According to the Science Advisory Table the Delta variant is about 50% more transmissible than Alpha (B.1.1.7, first discovered in the UK) and may be more dangerous, with the risk of hospitalization increased. It will likely be the dominant form of the virus in Ontario (and Canada), this summer. The scientists caution that it is critical to control the spread of this variant.
According to the same advisory body, having only one dose of any COVID vaccine is less effective against symptomatic disease for the Delta variant than for the Alpha variant. The first dose may still protect against severe disease, so its importance should not be diminished. However, the second vaccine dose is more than twice as effective against the Delta variant as just having one dose. That is the reason they urge us to accelerate getting second doses in arms.
On June 10th the Ontario government announced it was accelerating even further second doses in Delta hotspots where the variant is becoming dominant. However, it surprised many of us when it excluded once again those who received AZ.
The Twittersphere took on, urging the government to speed up the dosing intervals for persons who received the AZ vaccine. Reacting to the June 10 announcement, I said “RNAO is disappointed Minister Elliott didn’t announce interval change between AZ and Pfizer or Moderna. The time is NOW - Delta is catching up!!! MOST experts support 4-week interval!” Please continue to RT to encourage change.
Today, I was amongst the fortunate to get my second dose! In tweeting a selfie, I took the opportunity to push once again to shorten the dosing interval following AZ. Here’s for you to RT.
There is no doubt that Ontario MUST shorten the dosing interval to receive an mRNA vaccine following a first dose of AZ. The question is – how long will we have to wait for that decision, and why do we need to wait at all? Each day that passes is a missed opportunity to gain more protection against a dangerous variant.
IMPORTANT UPDATE: Just as I was finishing this commentary, the announcement reached my inbox that the Ontario government is reducing the required interval to 8 weeks from 12 weeks. Once again, the Twittersphere proved its power, even on a Saturday!
June is Pride Month
Pride Month is celebrated annually in June to celebrate the history, courage and diversity of the Lesbian, Gay, Bisexual, Trans, Intersex, Queer, Questioning, Two Spirit communities (2SLGBTQI+).
In honour of Pride Month, Pride Toronto will be hosting several virtual events showcasing more than 130 2SLGBTQ+ artists and concluding with two festival weekends on June 18-20 and June 25-27. The Pride parade will also take place again this year virtually on June 27, 2021. As part of this year’s virtual parade, RNAO’s Rainbow Nursing Interest Group has created a video wishing everyone a happy Pride Month.
POLICY UPDATES FOR ALL TO ACT ON & MUST JOIN EVENTS – OPEN TO ALL
Webinar: COVID-19 Webinar Series
June 14, 2021, 2:00pm - 4:00pm
Topic: Update on COVID-19 – Directions from the province and policy implications
We are now in the 16th month of COVID-19.
Join us for an update on current issues related to this stage in the pandemic. RNAO CEO, Dr. Doris Grinspun will outline recent directions from the province, discuss the policy implications from RNAO’s perspective and have a conversation with participants.
Issues to be discussed will include:
Presenter: Dr. Doris Grinspun, RNAO CEO
You can watch our May 10 webinar. Here is the description of that webinar:
Kick off National Nursing Week with us; we will be dedicating our COVID-19 webinar to your stories.
Nurses, other health providers and members of the public are welcome to join our webinar to pay tribute to the roles nurses have played during the pandemic. This webinar is focused on good news. You can share examples, words or stories of the nurses’ leadership: Their knowledge, compassion, bravery, dedication, collaboration and creativity as they have given it their all for patients this past year. Together, we will create a virtual wall of appreciation where you can share stories, upload images, take photos and share GIFs. The wall can be shared within your networks and on social media. Let's take time to collectively honour nursing and reenergize ourselves and our colleagues. We are an awesome mosaic of human richness!
Watch and read about earlier webinars here.
MOH EOC Situational Report
We are posting each day the Daily Situational Reports from Ontario's MOH EOC at RNAO’s website. That way, you can access the Ministry’s guidance at any time.
For a more detailed Ontario epidemiological summary from Public Health Ontario, you can always go here.
Here is a segment from the last Situation Report #449 for June 11:
Staying in touch
Keeping in touch remains important as we face the pandemic and other challenges in Ontario, in Canada and elsewhere. Feeling that we are part of a community and that we have each other’s backs helps us get through these challenges, becoming better people in the process. We are eager to hear how we, at RNAO, can best support you. Send us your questions, comments, and challenges. Recommend ideas for articles and webinars. Write to me at email@example.com and copy my executive assistant, Peta-Gay (PG) Batten at firstname.lastname@example.org. RNAO’s Board of Directors and our entire staff want you to know: WE ARE HERE FOR YOU!
Thank you for being there for your community – everywhere and in all roles! Together, in solidarity, we are strong and resilient. In Canada we see hope at the end of this long pandemic tunnel. Vaccines arrive in large quantities and the rollout is speeding even more. We must not forget, however, about our privilege. Canada has purchased more vaccines than what it needs, while 9 out 10 countries have almost nothing. Like in other challenges we face, such as racism, Islamophobia, and other forms of discrimination, we are not safe until everyone is safe. Vaccines for all – literally for all, across the world – must guide policy in the upcoming 12 months. Let’s learn from the 16-month pandemic and take real action to build a better world.
To everyone – THANK YOU! Please take care of yourself and know that RNAO always stands by you!
As we have said before – and everyday becomes truer: The silver lining of COVID-19: Coming together and working as one people – for the good of all!
Doris Grinspun, RN,MSN, PhD, LLD(hon), Dr(hc), FAAN, FCAN, O.ONT
RECENT BLOG ITEMS:
5 June - RNAO’s continuing media profile: The May report – go here
5 June - RNAO supports Premier Ford's announcement on schools as risk is too high – go here
29 May - Vaccination passport apps could help society reopen – go here
29 May - Email updates highlight best new evidence about COVID-19 – go here
23 May – NPs speak about LTC during the COVID-19 Pandemic – go here
23 May – Three surveys on the impact of COVID-19 on Canadian nurses – go here
23 May – Exemption of nurses and other health-care workers from Bill 124 – go here
23 May – RNAO’s statement on the government’s phased-in re-opening plan – go here
23 May – Remembering Charlotte Noesgaard (1948-2021) – go here
15 May - Nursing Now Ontario Awards Ceremony – go here
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8 May - Nurses must be fully vaccinated immediately, RNAO demands – go here
8 May - A bill to support individuals with assistive devices for mental health – go here
8 May - Action alert: Ensure global vaccine access, prime minister! – go here
1 May - RNAO statement on the passing of RN Lorraine Gouveia – go here
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24 April - RNAO launches new policy webpages – go here
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17 April - Vaccine engagement as a tool to address marginalization and exclusion – go here
17 April - Here's how the COVID-19 pandemic could play out in 2021 and beyond – go here
17 April - Reacting to the latest Ontario government public health measures – go here
10 April - RNAO and NAN sign Relationship Accord to improve health across NAN Territory – go here
10 April - RNAO media release on public health measures and vaccination rollout – go here
10 April - 3 ways to vaccinate the world and make sure everyone benefits, rich and poor – go here
3 April - Government’s “shutdown” announcement doesn’t go far enough – go here
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27 Mar - Provincial budget fails to deliver urgent nursing investments to care for Ontarians – go here
27 Mar - Government's reopening plan threatens the health of Ontarians – go here
20 Mar - Preliminary results of RNAO‘s Work and Wellbeing Survey – go here
13 Mar - Getting it right – go here
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6 Mar - RNAO’s continuing media profile: The February report – go here
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6 Mar - Webinar: Understanding wellness in Indigenous wisdom traditions for caregivers – go here
We have posted earlier ones in my blog here. I invite you to look.
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