The COVID-19 pandemic will forever change many things in medicine. It’s my hope that safety for health-care providers is among them.
Our hospitals serve and house the most vulnerable. Yet we continue to see large outbreaks of hospital-acquired COVID-19 in patients and health-care workers (HCWs) alike. Take Ontario, for example. From March 2020 to March 2021, the province reported 5,363 cases of COVID-19 from hospital outbreaks. Data from February 2020 to December 2020 show hospitals were responsible for 8.1 per cent of all COVID-19 outbreak-associated deaths and about 7 per cent of all COVID-19 deaths over a similar timeframe. Retirement homes were responsible for 11.4 per cent of outbreak-associated deaths while long-term care (LTC) homes accounted for 79.1 per cent. COVID-19 outbreaks in places with elderly and vulnerable people are deadly; we need to remember this includes hospitals. And this data was also compiled prior to variants of concern (VOC) now circulating widely.
Protecting HCWs protects our patients but 50 per cent or 80 per cent vaccine efficacy is not enough. Canada has made the difficult decision to space our dosing between vaccinations by four months. Caroline Quach-Thanh, chair of the National Advisory Committee on Immunizations (NACI), has made it clear this decision was made based on a lack of vaccines, not because of robust data supporting it. In fact, the supporting data is arguably weak, especially from the perspective of HCW vaccinations.
After a single dose, vaccine efficacy (VE) in the Pfizer RCT is 52 per cent. The 95 per cent confidence interval (CI) ranged from 29.5 to 68.4, meaning given the variability that comes with clinical trials the real value very likely falls anywhere between 29.5 to 68.4, a pretty wide range. The U.K. has re-examined the data stating that cases occurring shortly after receiving the vaccine (and before the vaccine has had time to build immunity in the body) should be excluded. When the data was re-examined to consider only cases between day 15 and 21, VE was estimated at 89 per cent (95% CI, 52 to 97%). Keep in mind this was a period of days monitoring patients, not four months. Recently published interim estimates from a U.S. study on the Moderna vaccine in health-care and essential workers has demonstrated an 80 per cent vaccine efficacy (95% CI, 59-90) after a single dose. A retrospective study of the Pfizer vaccine in Israel looked at more than 9,000 HCW and found that during the study period, 170 became infected with COVID-19. Of those, 89 (52 per cent) were unvaccinated, 78 (46 per cent) tested positive after the first dose and three (2 per cent) tested positive after the second dose. The researchers calculated an adjusted rate reduction of 30 per cent (95% CI, 2-50) for the first 14 days after the first dose. It does not state how long after initial doses HCWs acquired COVID-19.
Given the very wide confidence intervals, different health-care systems (with different public health rules and PPE standards), short-duration studies, and lack of data with variants of concern, it is easy to see why the NACI recognized that its decision is based on supply, not data.
Is it possible that a vaccine efficacy level of over 80 per cent will be confirmed after a single dose? Absolutely. But the bigger question is, how many HCWs are we “OK” with acquiring COVID-19 and what are the consequences to our HCWs and our vulnerable patients when HCWs get COVID-19?
I’d argue we should be doing everything we can to prevent every single case of HCW illness and this includes fully vaccinating them as soon as possible.
If you haven’t yet had the experience of witnessing a colleague suffer from COVID-19, I can tell you without hesitation it is horrible. Witnessing colleagues hospitalized and having their lives, their families’ lives and their livelihoods threatened from a preventable workplace infection is nothing short of awful for everyone.
But the harm does not stop there:
Less discussed is the concern that HCWs have for themselves and their families if they are exposed to infectious colleagues at work;
Less discussed is the HCWs who have slept or are sleeping in trailers or hotels and purposefully isolating themselves to protect those they love because of the fear and likelihood of acquiring COVID-19 at work;
Less discussed and less measured is the number of other colleagues requiring isolation and the staffing shortages this creates. These gaps can last months and undoubtedly leave infected colleagues not only dealing with COVID-19 but also with guilt over their own absences from work during a period of chronic understaffing.
Some departments have built significant redundancies into physician schedules to protect from staffing shortages but many departments do not have the manpower or flexibility to achieve this. Sick colleagues can leave significant gaps and shortages in nursing, pharmacy, clerk and environmental services (to name a few) schedules.
All of this impacts patient care and HWC burnout. In some long-term care homes, staffing shortages were so severe public health mandated support from neighbouring hospitals or the military. It should also come as no surprise that staffing issues have been flagged as one of the contributing factors to the high mortality seen in LTC homes.
The intentional decision to not fully vaccinate a portion of HCWs while fully vaccinating those who happened to be lucky enough to receive both doses before the change to a four-month interval has led to significant moral injury and sends a message, whether intentional or not, that we do not prioritize HCW safety and wellbeing.
HCWs should not be made to feel like it’s a choice between protecting them vs. protecting society – governments need to do both and prioritize both. Advocacy for vaccinating HCWs should not be seen as advocacy against vaccinating other populations. We need to change the way we think and shift to a culture that prioritizes HCW safety and precautionary principles. We can’t continue to pour our hearts and souls into protecting our patients if we don’t first protect ourselves.
It’s time to do, and demand, better.