Primary Care Open Forum Summary Document (Apr 7)
COVID-19 Support for Primary Care
Discussion Forum – April 7, 2021
To support primary care during the COVID-19 pandemic, East Toronto Family Practice Network (EasT-FPN), in collaboration with Michael Garron Hospital’s Dr. Jeff Powis - Medical Director, IPAC, hosts a virtual Primary Care Q+A Open Forum to provide clinical & practice recommendations. Join us bi-weekly. Get additional practice support and strengthen East Toronto, by becoming a member of the EasT-FPN.
Key Updates & Summary of Apr 7/2021 Discussion
We are currently in a third wave. The number of COVID-19 cases continue to increase. Compared to the other waves, the patients in the third wave have a younger age group. It has been hard staffing the ICU units due to the increase in volume.
We are hoping to have a more useful strategy to vaccinate those in high risk neighbourhoods. We are focusing on FSA neighbourhoods, mainly M1H, M4H, M3C, and M4A and will be administering vaccinations through mobile work and informal community hubs. This will be given to anyone over 18, but the limitation will be vaccine access.
We have started looking for patients in our family practices that are in the FSA neighbourhoods. We have identified 900 patients at SETFHT and 1500 at Albany clinic. We will share the EMR strategies for those who participate in primary care leadership groups to help their patients book vaccine appointments.
Thank you for your continued support in signing up for shifts at the pop-up clinics and vaccination clinics. There are currently high testing rates at pop-up clinics and we are short staffed particularly at the pop-up clinics.
Question and Answer:
Q: AstraZeneca has been linked to coagulopathy and thrombocytopenia. Did any of the known cases have identifiable risk factors?
A: It is restricted to mostly younger individuals and more common in females. It may have been from a “bad batch” of the vaccine, but the incidence rate is extremely low. The current guidelines is to use it for individuals over 55, but those under 55 could receive the vaccine with consent. It is important to weigh the risks vs the benefits of getting the vaccine. Here are some more resources regarding the COVID-19 vaccines.
Q: Can you give advice about counselling patients on the effectiveness of the 3 different COVID-19 vaccines after the first shot? At the vaccine clinic there were numbers of Moderna being 92% effective 2 weeks after the first shot and 94% after the second shot. Is this accurate? I have seen similar numbers for Pfizer, however I also see a wide range of effectiveness depending on the source. How are you counselling patients?
A: We have to be careful using clinical trial numbers. It is hard to compare one study to another study. The SIREN study in the UK demonstrates the effect of a single dose for 72% effective then 85% effective after 2 doses for both symptomatic and asymptomatic infections. Regardless of the numbers, both mRNA vaccines are extremely effective.
Q: Can you review the counselling for patients regarding the effectiveness of the COVID-19 vaccines and the longer dosing interval? Do we know how the longer dosing interval impacts the overall efficacy?
A: We will get better in understanding who needs their second dose earlier and who can wait. We would not do this if we had enough vaccine supply, but it is done to maximize the immunity in communities of high risk neighbourhoods. The decision is at the political level.
Q: We have patient facing providers at our centre who are waiting for their second dose. They have raised concerns about their safety seeing patients especially with Variants of Concerns and our increased volume. It is difficult to reassure them especially when it comes from some of us who are already fully vaccinated.
A: There are strict guidelines, but there is still protection with one dose. Hopefully, the advocacy for changing that with healthline workers will have an impact.
Q: In primary care we are being asked to help facilitate patients getting their second dose sooner. These are patients who have had their first shot via a vaccination site, but are also presenting with notes from specialists, oncology, and respirology stating they should have their second shots sooner than 4 months. Do you have any ideas on how to strategize these here in the east?
A: I suggest sharing the provincial direction with the specialists. They can reach out to the Member of Provincial Parliament if they would like to advocate. Here is some information regarding which patients are eligible to receive their second dose sooner than 4 months.
Q: Do you have any idea why we are so slow to roll out the vaccines? We staffed the Wellesley Community Vaccine clinic in St. Jamestown and had to cancel this week because we did not receive our vaccines. However I hear that they are "sitting in freezers''? Where is the breakdown ?
A: At the end of the next week, we will have 0 doses in the freezer. If we do not receive any more doses, we will have to cancel our appointments. We will make it publicly known that we are shutting down vaccination centres due to the lack of vaccine supply. In the East End, we use all vaccine doses that we receive and we do not hold any in our freezers.
Q: Are biologic and other arthritis immunosuppressants being considered regarding timing for their second dose of the COVID-19 vaccine?
A: They are not currently listed as being able to receive their second dose.
Q: Do you know if the second dose can be different from the initial dose received? I have many clients who received AstraZeneca and want the second dose to be mRNA.
A: There has not been any formal guidelines yet. There is increasing evidence that receiving a second dose of a different COVID-19 vaccine is safe and efficacious. It has not been studied in large populations yet, but I believe they should work equally well.
Q: Once we identify patients based on postal code, who will call the patients?
A: Administrative assistants and family physicians will be calling patients.
Q: Is there more information about what constitutes as "diagnosis of mental disorder" in Phase 2?
A: Phase 2 will have gatekeeping for the listed conditions. Hopefully, they will be able to do it based on where people live and their type of jobs, rather than medical conditions. If that is the case, I hope the conditions will be clearly defined.
Q: There is a pilot for primary care to sign up for rapid testing. Are there any useful ways you think we should employ this and sign up for this in various regions?
A: We can use rapid testing for everyone who comes into the clinic in a waiting room. For home based visits, they can be conducted before the patient is assessed. You may consider doing rapid testing three times a week for the staff at your primary clinics.
Q: With all of the different criteria for who is eligible for vaccines, do you recommend us turning people away at the clinic if they are essentially part of phase 3?
A: We do try to have people attest that they meet the criteria when they are signing up. If someone does not meet the criteria, it is fine to challenge them, but remember they waited in line and it is probably okay to give the vaccine. We should focus more on vaccine delivery.
Q: Are all COVID-19 vaccines equally effective against all Variants of Concerns?
A: It seems that some COVID-19 vaccines are superior to some Variants of Concerns. In Ontario, we are seeing lots of B117 variants. In the test tube they neutralize well. There is increasing evidence to say the mRNA vaccines work well against them.
Q: Can you let us know how best to advocate to release the vaccines from the freezers? Should we direct it towards Members of Parliament or Toronto Public Health?
A: We are struggling with trying to figure out who is best to advocate to. There has been a provincially driven direction to increased vaccinations in FSAs. If the East End is being vaccinated with an efficient method of delivery, we should be receiving more vaccines to help reach out to FSAs.
Q: Is the standby list no longer available? What is the best way to advocate for the standby list that MGH had to offer?
A: We were trying to find a way to equitably deliver doses and had over 70,000 people sign up on the standby list. It did not seem to be very valuable. We did use it to find the immunosuppressed patients that were prioritized for vaccinations. We now have a different mechanism to use the extra doses at the end of the day in the local community.
Q: Do you have any thoughts on plans for summer vacations?
A: We need to look at the stay at home order. It will be hard to come down from the number of current cases. Hopefully, late summer it will be safe to travel locally, but it is still too early to say.