CoronaVac/AZD1222 shows higher neutralizing antibody activity to original Wuhan strain and Alpha and Beta variants compared to homologous two-dose CoronaVac vaccine.
The neutralizing antibody levels of mRNA vaccine in adolescents 12 to 17 years of age was similar to young adults 18 to 25 years.
A study evaluating safety in 140 pregnant women showed no maternal or neonatal deaths following the FDA emergency use of vaccines.
Vaccine effectiveness of Pfizer and Moderna dropped during the Delta variant predominant period from May to July of 2021.
The odds ratio of vaccine effectiveness in men was higher with the Moderna vaccine and in women was higher with the Sputnik vaccine whereas Pfizer and AstraZeneca had similar odds ratio in both genders.
On August 2021, the BNT 162b2 (Pfizer) vaccine was fully approved by the FDA based on an initial Pfizer’s study (six months after vaccination clinical trial) and other real-world safety evidence.
An interim analysis in fully vaccinated 4,217 frontline workers in the USA with Pfizer-BioNTech , Moderna and Johnson & Johnson during Delta variant–predominant weeks, found Vaccine effectiveness declined to 66% compared with 91% during the months preceding Delta predominance.
August 25, 2021
There are further findings supporting the effectiveness of vaccines in pregnant and breastfeeding women.
High vaccine efficacy (92-93%) was seen in adolescents between 12 and 15 years of age.
A 9-week delay in administration of second dose of Moderna (mRNA-1273) could maximize effectiveness of vaccine in preventing infection.
Analysis of serum SARS-CoV-2 anti-spike IgG (GMRs) at 28 days post boost vaccination indicated that the heterologous schedules(ChAd(Vaxzevria)/BNT(Comirnaty,Pfizer) and (BNT/Chad) schedule had higher GMRs than homologous schedules (BNT/BNT or ChAd/ChAd) vaccination.
There is evidence that vector vaccines such AstraZeneca Chad0x1-S have active long-lasting immune response. On the other hand, emerging evidence shows a decline in antibodies 3-6 months post Pfizer vaccination and may require booster.
Israel presented data suggesting that the Pfizer/BioNtech vaccine's effectiveness against severe disease in 60-year-old people has declined from 97% in January to 81% due to delta variant.
19 % of fully vaccinated healthcare workers in Israel who developed breakthrough infections reported "long COVID" symptoms for more than 6 weeks
60% of transplant patients who received a booster dose saw a rise in neutralizing antibodies compared to the placebo group.
The CDC changed their recommendation near the end of July 2021 stating that all individuals regardless of vaccination status should wear a mask in public indoor settings "in areas with substantial and high transmission.
August 23, 2021
- Public Health Ontario estimates that 89.6% of the cases in ON were due to Delta variant with an R of 1.36 on August 10, 2021, compared to 83% cases and R of 1.0 on July 26, 2021. The Alpha variant was down to 2.8% and 7.3% to Beta and Gamma variants in the same period of time.
- Technical briefing by Public Health England on Delta Variants in UK on August 6, 2021, report Delta variant accounted for approximately 99% of sequenced and 98% of genotyped cases from 25 July to 31 July 2021 in the UK.
- CDC report significant increase in the incidence of Delta variants in Mesa County, Colorado (from 43% for the week ending May 1 to 88% for the week ending June 5)–where only 36% of eligible residents in the county were fully vaccinated compared to the rest of the state (44%).
- CBC News on August 11, 2021, reported first three cases of a Delta sub-lineage called AY.3, also known as "delta plus" in Manitoba — but only one of those cases is now active.
- CBC News on August 7, 2021, reported on 3 Delta outbreaks in Saskatchewan including one school, a private gathering and widespread community outbreak in the north – as of Aug 6th, the North accounted for 40% of the 766 delta cases in Saskatchewan, 30% in Regina and 21% in Saskatoon.
-The occupancy of intensive care beds in Indonesia passed 90% of capacity on Sulawesi Island, with levels in three regions of Sumatra Island at 80% capacity due to Delta variant surge as reported by CIDRAP on August 9, 2021.
- 414 of the 539 samples analyzed by genomic sequence from three COVID triage centres in India, Delta variant was present in 72.4% (134/185) of unvaccinated people), 68.1% (164/241) in partially and 74.3% (84/113) in fully vaccinated groups., The presence of moderate/severe illness among vaccinated group was 6.7% compared to 19.3% for unvaccinated group (p = 0.003). Seven deaths were recorded among the unvaccinated group, three among partially vaccinated and no deaths were reported among the vaccinated group
August 9, 2021
- weekly surveillance from Ontario as of July 2021 indicate travel related cases only make up 1.7% of all cases, but weekly proportion increased from 7.7% to over 10%
- In Ontario, 1Nov and 17Jul, there have been 236 confirmed cases of re-infection ,2.5% in >80 age group, 43.6% in 20-39 age group and 30.9% in 40-59 age group
- Public Health Ontario estimates that 83% of cases in ON due to Delta and Alpha down to 6.2%, 9.7% Beta/Gamma Effective R of Delta 1.0, Alpha 0.74, Beta 1.29, Gamma 0.77
- SARS-CoV-2 sequenced from wastewater samples in 9 different regions in Israel from August 2020–February 2021 - VOC identified include Alpha, Beta, Gamma, B.1.429 (USA/California), Eta, Iota, and A.23.1 (Uganda)
- SARS-CoV-2 genome sequences of 12,476 patients in the Houston Methodist healthcare system diagnosed from January 1 through May 31, 2021, found 207 breakthrough cases in fully vaccinated patients including VOC. 72 of breakthrough cases required hospitalization.
- upsurge by COVID-19 viral variants in Japan, daily positive cases (DPC) data (from early days of COVID-19 to early March 2021) using a machine learning model, an average increase of 20-40% in DPC was observed with emergence of Alpha, 20% increase in effective reproduction number
-New CDC guidance recommending masks for vaccinated individuals in areas with high virus activity due to Delta surges, recommend that all schoolchildren, staff, and teachers should mask indoors regardless of vaccination status
- CDC report on Delta vaccine breakthrough cases USA - new report in MMWR from Barnstable County Mass. of 469 cases, 133 sequenced - 90% of sequenced were Delta, 74% occurred in fully vaccinated individuals, 79% of breakthrough infections were symptomatic. The viral load was similar in vaccinated and unvaccinated individuals, 4/5 hospitalized fully vaccinated, no deaths.
- Jun19-Jul23 CDC report, COVID cases increased 300% nationally in the USA, followed by increased hospitalizations and deaths - 8/10 sequenced cases in USA are now caused by Delta
- Reported steepest increase among 15-24 years due to NPI relaxation in 20 EU and EEA countries – however there is limited increases in >65, hospital occupancy rate remains stable in most countries and ICU occupancy decreasing in most countries
- Public Health England Risk assessment of Delta variant (England 23Jul) indicates high risk of increased transmissibility with high confidence, increased risk of hospitalization compared to Alpha (prelim data suggests equivalent case fatality rate), high risk of reduced vaccine effectiveness with high confidence - more pronounced after first dose, continues to be high after 2 doses and protection against hospitalization maintained.
- Delta breakthrough cases 19.7% compared to 5.8% for all other variants from one hospital system in Houston (3,913 samples from March 15 – July 3), 6.5% of all COVID-19 cases in fully vaccinated, relatively few required hospitalization
- Research on Lambda infectivity suggest that Lambda was not first in Peru Dec 20 but Argentina (Nov 20). Predominant spread in Peru, Chile and Argentina, Virological assays indicate increased infectivity of Lambda vs wild-type, Antibody assays show that Lambda is 2.63-fold more resistant to Pfizer vaccinee sera than wild-type.
- Reached a prevalence as high as 90% in Peru as of July 2021 after first reported in Aug 2020
- Has moderately reduced sensitivity to neutralization by convalescent sera and REGN10987 monoclonal antibody, slightly reduced sensitivity to BNT162b2, mRNA-1273, and CoronaVac6-elicited antibodies, while retaining full sensitivity to REGN10933
There is no separate review for version 10 since ESR versions 10 and 11 were combined into this review.
Asamoah, G; Badea, A; Lee, S; Shumilak, G; Reeder, B; Groot, G; Muhajarine, N; Miller, L; Howell-Spooner, B. What is the epidemiology of variants and what are the implications for healthcare? 2021 Aug 27, Document no.: EOC031801v011 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 38 p. (CEST rapid review report).
August 18, 2021
- Proof of vaccine “freebies” to customers are slowing
- Many vaccine “lotteries” have now ended with prizes being given out, retrospective analysis of vaccine numbers and assumptions regarding causality will likely follow in the near future
- More state-sponsored incentives such as partnerships with ride-share companies, childcare centers, etc.
- Post-secondary institutions offering incentives mostly in the form of raffles with grand prizes of cash/scholarships for staff/students with proof of vaccination
- ESN evidence synthesis found 8 systematic reviews providing some evidence of positive impact of financial incentives with or without other interventions for non-COVID-19 vaccines, 3 reviews found no effect
- Several European countries (Greece, France, Italy) mandating vaccination for healthcare workers with refusers facing sanctions/fines/suspensions/job loss
- Ontario requiring hospitals, licensed care homes and other high-risk settings such as post-secondary institutions, women’s shelters, youth care facilities, etc. to establish vaccination policies – while vaccination will not likely be mandatory, those who are not vaccinated will be subject to frequent antigen testing.
- In Pakistan, the government will be blocking the SIM cards of vaccine refusers, and allowing business to resume in areas with a vaccination rate of greater than 20%
- In Indonesia, vaccine refusers will have any social aid suspended and face fines
- In the Philippines, the President is threatening to find ways to legalize arresting and forcing vaccination for refusers
- A retrospective analysis of vaccination data in Israel found a peak of 2nd dose vaccinations correlating with the exemption of quarantine for vaccinated individuals beginning January 17th, and high rates continued following the day with the highest new daily cases as well as the day of highest fatality rates
- Israeli survey of 500 individuals found that 21% of respondents were not intending to vaccinate. The implementation of the ‘Green Pass’ would possibly or definitely convince 31% of respondents, but 46% of respondents indicated that it would not.
May 27, 2021
Vaccine incentives are beginning to emerge in North America in various forms due to a lagging vaccine uptake combined with the threat of SARS-CoV-2 variants
Vaccine incentives range from free items and discounts offered by businesses to customers to financial incentives offered by companies to employees such as paid time off or cash bonuses
Some states/provinces have developed vaccine incentive programs offering large lotteries with cash prizes or scholarship awards, cash incentives or offers for free/discounted entertainment options
Some incentives are specifically geared to high priority populations, for example offering gift cards to anyone within a certain age demographic that receives a vaccine at certain sites, or offering the single-dose Johnson & Johnson vaccine at walk-up vaccination sites in subway stations with the addition of free transit passes
Badea, A; Reeder, B; Groot, G; Ellsworth, C. What are other jurisdictions offering for incentive-based COVID-19? 2021 Aug 24, Document no.: EOC210501v2 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 10 p. (CEST rapid review report).
New search completed August 17, 2021 containing 8 grey literature sources and 51 published journal articles including preprints.
Review of new search resulted in conformation of previously compiled information, relevant evidences and updates have been added to evidence table to reflect updated review.
Vaccine hesitancy was most commonly found in females and pregnant women as males generally showed greater willingness towards vaccine uptake.
Regardless of country and phase of the pandemic, there were evidences of widespread mistrust in the healthcare system and the governments with speed of vaccine development and approval. The greatest impact was seen in minority groups and people of colour.
Significant uptake of vaccination is due to the tailored recommendation of health provider in hesitant population, this has reinforced the importance of vaccination and also promoted vaccination of children with hesitant parents.
Previous vaccination has a positive influence on covid 19 vaccine uptake, (most popularly with influenza vaccine)
Higher age and underlying conditions/vulnerability to diseases along with employment and retirement had significantly lower vaccine hesitancy.
Greater financial incentives were some of the modifying of attitudes towards vaccination.
Social media and internet had mixed impact on hesitancy- restriction of certain vaccines had a direct impact on vaccination uptake whereas some reinforced confidence.
May 10, 2021
New search completed April 19, 2021 containing 29 grey literature sources and 128 published articles
Review of new search resulted in confirmation of previously compiled information, review update deemed not necessary at this time, relevant evidence has been added to the evidence table to reflect updated review
February 1, 2021
Vaccine hesitancy towards the COVID vaccine varies from 2% to 44% in the general population, depending on country, phase of pandemic and specific population
Vaccine hesitancy tends to be lower in healthcare workers than the general population, but still exists at rates up to 56%, again, dependent on the country of residence and phase of the pandemic
The most commonly cited reasons for vaccine hesitancy are concerns about the efficacy and safety, largely due to the expedited testing/approval process
Country of residence and corresponding trust in government/pharmaceutical industries can have a significant role in vaccine acceptance
Strategies to increase vaccine uptake should range from personal-level interventions such as patient education materials to health system level interventions such as healthcare provider training and targeted population vaccine acceptance campaigns
Jagwani, M; Badea, A; Groot, G; Mueller, M; Young, C. What are the causes of vaccine hesitancy? What programs/approaches have been successful in reducing vaccine hesitancy? 2021 Aug 17 Document no.: EOC012201v3 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 15 p. (CEST evidence search report).
Long COVID-19 is likely to increase healthcare demands across the health system, including emergency departments, hospital admissions, primary care visits, specialists appointments, and home care and rehabilitation services.
The clinical care burden of long COVID-19 is the greatest in the first 3 months after testing and is likely to place the greatest demand on primary care services.
Patients with severe COVID-19 illness are more likely to place longer-term demands (4-6 months) on specialist care due to respiratory, circulatory, endocrine, metabolic, psychiatric and unspecified conditions.
McLean, M; Williams-Roberts, H; Reeder, B; Howell-Spooner, B; Ellsworth, C. What are long COVID's demands on the healthcare system, and its severity of the illness? 2021 Jul 12, Document no.: EPM210602 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 23 p. (CEST rapid review report).
The frequency of Long COVID symptoms varies widely across studies based on populations studied, duration of follow up and methods of assessment of symptoms.
It is estimated that 1 in 50 persons experience Long COVID symptoms after 12 weeks; however, higher estimates up to 80% have been reported in studies with a greater proportion of persons who were previously hospitalized. A recent study of a mixed cohort of 96 persons found that only 22.9% had no symptoms at 12 months post diagnosis.
A wide range of symptoms affecting multiple organ systems has been reported. For many persons symptoms improve over time while others experience persistent and/or new symptoms. Among studies with the longest duration of follow up, the most frequently reported symptoms included fatigue (up to 65%), dyspnea (up to 50%), headache (up to 45%), anosmia/ageusia (up to 25%), cognitive memory/concentration (up to 39.6%) and sleep disorders (up to 26%).
Few studies estimated the duration of symptoms with estimates ranging from 2.2% for 6 months and 27% for 7-9 months.
The mechanism(s) leading to Long COVID remain unclear but those experiencing post acute sequelae tend to be older, have a greater number of symptoms during the acute phase of illness or manifest specific symptoms and live with multiple comorbid conditions such as obesity.
The lack of consensus on a definition of Long COVID contributes to marked variations in robust prevalence estimates.
Williams-Roberts, H; Groot, G; Reeder, B; Howell-Spooner, B; Ellsworth, C. What is the incidence and duration of Long COVID cases? 2021 Jul 09, Document no.: EPM210601 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 19 p. (CEST rapid review report).
Requiring proof of vaccination for entry into another country is not a new idea. There are regulations that need to be followed to set up a “vaccine passport” in relation to international travel (International Health Regulations (IHR) (2005))
At present the World Health Organization does not recommend vaccine passports for international travel, but they are working on a standard Smart Vaccination Certificate technical specification and standards to allow for harmonised processes to include COVID-19 vaccines into an updated version of the IHR (2005)
Countries around the world are beginning to put vaccine passports into place for international travel, as well as in some countries within country travel and access to services or businesses including Israel, France, Italy, Denmark, and the EU
The Canadian Federal government is supportive of a vaccine passport for international travel but recognize the issuing of vaccine passports will need to be province led
As of May 13, 2021, the province of Quebec has begun issuing a downloadable QR code that individual can keep on their smart phone.
As of June 9, 2021, the Federal government of Canada discussed easing restrictions for fully vaccinated Canadian citizens returning to the country
Ethical considerations in the use of vaccine passports include equitable access to vaccination (domestically and internationally), access to technology (eg. Smartphone passports), marginalization, or stigmatization especially among historically racialized groups, and socially isolated populations
Legal considerations include
o Clarifying who has the legal authority to require proof of vaccination,
o Ensuring that if new legislation is created and implemented it is in line with all pre-existing legislation (Charter of Rights and Freedoms, Human Rights Codes, privacy legislation, employment legislation),
o Ensuring that, if created by the government, there is coordination of the Provincial and Federal governments for international travel with respect to jurisdictional overlap, security of information, fraud
Health care facilities should be able to legally enact vaccination policies for patient-facing employees so long as they allow for exemptions due to medical inability or bona fide religious, or conscientious beliefs
Six in ten Canadians (61%) expect vaccine passports to be widely used in Canada by the end of 2021, the same proportion (61%) of Canadians also agreed that only vaccinated people should be allowed to engage in events involving larger crowds such as public transit, air travel, or attending cultural and sports events
Lashta E, von Tigerstrom B, Reeder B, Groot G; Miller, L; Mueller, M. What are the ethical/legal aspects of vaccine requirements? 2021 Jun 21, Document no.: EOC210503 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 25 p. (CEST rapid review report).
Badea, A; Groot, G; Reeder, B; Young, C; Ellsworth, C. What are legitimate exemptions/contraindications for COVID-19 vaccines from a medical point of view? 2021 Jun 10, Document no.: EOC210502 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 8 p. (CEST rapid review report).
Cohort studies identified worsening mental health outcomes, including depression, anxiety, scores on the Strengths and Difficulties Questionnaire (SDQ), and other subjective mental health measures.
Cross-sectional studies reported post-pandemic prevalence rates of 7%-44% for depression, 6%-47.5% for anxiety, and 3%-22% for PTSD. Worsening sleep quality and increased frequency of substance use were also reported. Effects on self-harm and suicidality are inconclusive.
Risk factors for worsening mental health included identifying as female, older age or higher school grade, and increased use of technology or social media. Exercise was found to be protective.
Sulaiman, F; Hamid, E; Muhajarine, N; Dalidowicz, M; Miller, L. How has COVID-19 and the public health response to COVID-19 impacted mental health outcomes on children 5 to 18 years (school-age)? 2021 Jun 09, Document no.: PH021701 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 18 p. (CEST rapid review report).
The group designated in Saskatchewan as Clinically Extremely Vulnerable (CEV) is a heterogenous clinical population with factors that impair their immune response to differing degrees.
Very Limited evidence is currently available to assess the immune response following vaccination is selected clinical populations; no evidence is available to assess vaccine efficacy or effectiveness in these populations. The clinical relevance of measured immune response with respect to protection from disease is still uncertain.
In considering the immune response of the CEV population, it is recommended that the absolute difference in immune response between 1 and 2 doses be considered, as it is possible some patient groups will have lowered protection regardless of vaccine strategy.
In terms of clinical subgroups:
oOrgan transplantation recipients on immunosuppressive medication: solid organ transplant recipients receiving anti-metabolite maintenance immunosuppression therapy were less likely to develop an antibody response to an mRNA vaccine, compared to those receiving other types of therapies (37% vs 63%). In a study of 242 kidney transplant recipients on immunosuppressive therapy only 10.8% became seropositive at 28 days after a single dose of mRNA vaccine.
oCancer: A study of 151 elderly patients with solid and hematological malignancies and 54 healthy controls who received one or two doses of BNT162b2 (Pfizer-BioNTech) vaccine shows approximately 39% of solid cancer patients, 13% of hematological cancer patients, and 97% of healthy controls (p<0.0001) developed anti-S IgG 21 days following a single dose vaccine. However, response in solid cancer patients increased to 95% within 2 weeks of the second dose at 21 days.
oOther immunocompromising conditions (e.g., auto-immune disorders and therapy): some level of immunity is generated with vaccination; however, what this means clinically is unknown. It seems that ensuring the dosing is properly timed around biologic therapy is important.
Azizian, A; Lee, S; Shumilak, G; Groot, G; Reeder, B; Miller, L; Howell-Spooner, B. What are the risks or benefits of extended intervals between doses of COVID-19 vaccines compared to recommended dosing in extremely vulnerable populations? 2021 Apr 20, Document no.: EOC210302 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 15 p. (CEST rapid review report).
· Tele-ICU services are provided either by existing staff within the network to smaller centers, or outsourced to larger networks or independent firms
· The impact of tele-ICU adoption can result in a decrease in ICU mortality as large as 32%
· The impact of tele-ICU adoption of length of stay is mixed, with some studies reporting a significant decrease, while others report a small, but statistically insignificant decrease
· The degree of impact of tele-ICU adoption is linked to several factors such as yearly admission rates, location (urban vs. rural) and level of authority given to the tele-ICU team leading to increased positive impacts.
Badea, A; Groot, G; Reeder, B; Young, C; Ellsworth, C; Howell-Spooner, B. How to deliver remote ICU care for COVID-19 patients to avoid/prevent transfer from smaller communities to tertiary care hospitals. 2021 Apr 6; Document no.: CC210301 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 13p. (CEST rapid review report)
Pediatric cases of COVID-19 constitute between 1% to 10% of all confirmed cases of COVID-19; variation exists by jurisdiction.
Few case reports exist of confirmed child-to-other transmission. Contact tracing studies suggest that children are unlikely to be transmitters of the disease. Households are the most likely environments for transmission.
A recent large South Korean contact tracing study however (in pre-print) found that household COVID-19 transmission rates for children age 10-19 were significantly higher than in adults; transmission rates for children age 0-9 were relatively low.
AUGUST 7th, 2020 UPDATE: No new studies examining secondary attack rates of pediatric index cases were found. Studies continue to suggest low transmission from pediatric cases, and high proportion of pediatric cases being asymptomatic to mildly symptomatic.
MARCH 9th, 2021 UPDATE: Variants of Concerns are an emerging threat, but literature on pediatric prevalence and transmissibility is sparse. The British variant seems more transmissible (secondary attack rate higher) but follows the same age-related distribution of cases seen earlier in the pandemic.
Sulaiman, F; Coomaran, V; Muhajarine, N; Dalidowicz, M; Miller, L. What are the effects of the new COVID variants on transmission and school reopenings in pediatric populations? 2021 Mar 30; Document no.: PH030801 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 14p. (CEST rapid review report)
Although evidence is preliminary, vaccines have been effective in decreasing cases of SARSCoV-2 infections (COVID-19) and deaths among long-term care (LTC) residents by 89% and 96% respectively (Brown et al., 2021).
Estimated vaccine uptake among LTC staff in ON has been estimated at 68% as of March 5, 2021. The estimated relative reduction in COVID-19 cases among LTC staff is 79% (Brown et al., 2021).
Vaccination against COVID-19 protects in varying degrees against symptomatic infection and can be expected to have some effect on COVID-19 transmission; however, the extent of the impact on transmission is not fully quantified. In 3 separate small studies, all utilizing Pfizer Bio N Tech™ vaccine, the following results were observed: vaccine efficacy among partially vaccinated residents (n=463) was 63% (Britton et al., 2021), nasopharyngeal viral load was significantly decreased following a single dose (n = 10) (mean -2.4 log10 calculated by Ct value) (McEllistrem et al., 2021) and an immunogenic response was demonstrated following full vaccination (N= 134) as measured by antibody titres (15274 AU/mL) with no associated difference by age, gender, frailty or comorbidity (Salmeron Rios et al., 2021).
It is recommended that both vaccinated and unvaccinated persons in LTC continue to follow infection control measures such as masking, physical distancing, and hand/respiratory hygiene as long as there is community transmission of COVID-19 (European CDC 2021; ON Ministry of Health 2021; AB Ministry of Health 2021; Health Protection Surveillance Ireland, 2021; CDC Mar 5, 2021; WHO 2021; Brown et al., 2021; Centre for Health Policy Evaluation in LTC, 2021; Love et al., 2021; Jaklevic et al., 2020).
Within Canada 5 provinces have currently prioritized designated family care givers for vaccination to facilitate their presence in LTC (British Columbia, Newfoundland, Nova Scotia, Ontario and Prince Edward Island; NIA 2021).
Family and friends provide critical support to residents of LTC homes as partners in care and as visitors, playing an important role in their overall health and well-being (NIA, 2021; Levere et al., 2021; CFHI and CPSI, 2021; WHO, 2021; Ranhoff et al., 2021). Emerging evidence shows that cessation of visiting has had a significantly negative impact on the well-being physical, emotional, and cognitive well-being of LTC residents and on the well-being of their families (WHO, 2021; Levere et al., 2021; Suarez-Gonzalez et al., 2021; NIA, 2021; Dhama et al., 2021).
Policy changes pertaining to COVID-19 should be informed by all impacts on the health and well-being of LTC residents and their families and friends, beyond the direct effects of morbidity and mortality due to COVID-19 (Levere et al., 2021; Suarez-Gonzalez et al., 2021; WHO, 2021; Dhama et al., 2021; NIA, 2021). Policy guidelines for healthcare decision makers have focused attention on the harms of stringent visitor policies and the need to reintegrate family/designated caregivers for every resident (CFHI and CPSI, 2021; NIA, 2021; WHO, 2021; ON Ministry of Health, 2021, BCDC 2021).
Available data to inform policy on the impact of strict visitation policies and social isolation in LTC is limited and ongoing data collection is required (Suarez-Gonzales et al., 2021; WHO, 2021; Levere et al., 2021 ).
Prioritization of family/designated caregivers in vaccine roll out policies is intended to address the balance of a more comprehensive definition of resident safety and well-being inclusive of quality of life and well-being with morbidity and mortality of COVID-19 (NIA, 2021; WHO, 2021; CFHI and CPS, 2021). Policies prioritizing family/designated caregivers may also reduce the enormous burden placed on LTC staff during the remainder of the pandemic (NIA, 2021).
Ward, H; Tupper, S; Boden, C; Dalidowicz, M; Mueller, M. What impact does COVID-19 vaccination have on visitation policies and transmission rates in LTC? 2021 Mar 29; Document no.: LTC012501 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 44 p. (CEST rapid review report)
Current recommendations suggest phased distribution of authorized vaccines and prioritization of the recipients (e.g., health care workers, frontline essential workers, and elderly population).
A concern that could exist with using AstraZeneca on critical populations is that it may have little coverage for mild-moderate B.1.351, which may have implications in transmission. This could be a concern in critical workforces if the variant becomes predominant, especially given the potentially higher transmissibility of variant. The literature is mixed but it is possible that AstraZeneca has lower efficacy than the mRNA vaccines.
Canadian National Advisory Committee on Immunization (NACI) recommends that in the context of limited vaccine supply, initial doses of mRNA vaccines should be prioritized for those at highest risk of severe illness and death and highest risk of exposure to COVID-19. On the other hand, US Advisory Committee on Immunization Practices (ACIP) recommends no product preference for the vaccines.
Just recently, NACI has expanded its recommendation for the use of the AstraZeneca vaccine to all people over the age of 18, now including those 65 years of age and over.
While Pfizer and Moderna vaccines are mRNA vaccines and need special logistical and transportation considerations, AstraZeneca and Johnson&Johnson (J&J) vaccines are viral vector vaccines that are easier to transport.
J&J is a single dose vaccine thus may be more appropriate in certain settings (such as homeless shelters and correctional facilities). Of note, there is no empirical evidence yet available to support this use; this suggestion is based simply on the nature of the vaccine.
Azizian, A; Shumilak, G; Lee, S; Reeder, B; Groot, G; Miller, L; Howell-Spooner, B. What are the differences between COVID-19 vaccines and how they should be distributed based on population group(s)? 2021 Mar 18; Document no.: EOC031001 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 19 p. (CEST rapid review report)
There is a lack of consensus around the clinical definition of Long COVID which in turn causes challenges with understanding the incidence and prevalence as well as the potential impact for the health care system.
Information about the natural history of Long COVID is incomplete but limited evidence suggests that the immune response trajectories differ for those with few or no symptoms compared to those with severe disease. Individuals with severe disease are more likely to exhibit immunological marker abnormalities but anyone can experience functional limitations.
The mechanisms underlying the development of persistent symptoms in Long COVID remain an enigma. Despite multiple theories, there is little empirical evidence for specific immunological and or biochemical abnormalities in samples of individuals with symptoms consistent with Long COVID.
Risk factors for Long COVID include female gender, older age, higher body mass index, pre-existing asthma and the number of symptoms.
Few studies explored the short-term impact of Long COVID on health care utilization patterns and found a higher impact for those with severe disease compared with mild disease.
Williams-Roberts, H; Groot, G; Reeder, B; Linassi, G; Basran, J; Dalidowicz, M; Mueller, M. Long COVID: What does it mean for the healthcare system and programs to deal with it? 2021 Mar 15; Document no.: EOC021901 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 37 p. (CEST rapid review report)
Vulnerable populations such as those experiencing homelessness are 20 times more likely to be hospitalised due to COVID-19, 10 times more likely to require intensive care for COVID-19 and 5 times more likely to die within 21 days of a positive test for COVID-19
Many organizations advocate for socially vulnerable populations to be considered priority populations due to their oftencomplex health needs and inability to fully execute best practices for infection prevention and control
Past experiences from Hepatitis vaccination (requiring 3 injections) and H1N1 pandemic influenza vaccination indicate that partnering with community organizations to provide vaccinations in shelters, community centers and other frequently accessed places along with education and access to known, trusted healthcare providers greatly increase the uptake of vaccination among socially vulnerable populations
Beyond sheltered populations experiencing homelessness, considerations for equitable vaccination programs for the general population should include plans for accessibility for all, including underserved geographic regions
Badea, A; Reeder, B; Hanson, L; Miller, L; Howell-Spooner, B. What are the vaccination strategies for vulnerable populations? 2021 Mar 12; Document no.: PH030401 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 33 p. (CEST rapid review report)
There is limited research examining COVID-19 ICU patients undergoing prolonged (>14 days) mechanical ventilation
Rates of prolonged mechanical ventilation, defined as > 14 days, among COVID-19 ICU patients ranged from 16.7% to 33.3%.
Overall, studies suggest that length of ICU stay range from 11 to 31 days and length of hospital stay range from 25 to 51 days among COVID-19 patients who have undergone prolonged mechanical ventilation.
Following ICU discharge, patients are admitted to general wards, subacute nursing facilities, pneumological sub-intensive units, rehabilitation wards or long-term acute care.
Groot, G; McLean, M; Fox, L; Mueller, M. What is the final disposition of post-COVID patients who require chronic ventilation in the ICU? 2021 Feb 27; Document no.: CC011101 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 37 p. (CEST rapid review report)
Although rapid antigen point-of-care tests (POCT) to detect SARS-CoV-2 (COVID-19) infection have the advantage of rapid result turn-around time compared to laboratory-based reverse-transcriptase polymerase chain reaction (RT-PCR) test, their sensitivity to correctly detect positive cases is lower (Larremore et al., 2020).
Increased frequency of testing compensates for lower test sensitivity of POCTs (See et al., 2021; Larremore et al., 2020). The majority of policy guidelines and public health directives recommend basing frequency of POCT on rates of community transmission or outbreak status of the setting (Public Health Canada, 2021; Ontario Ministry of Long-term Care [LTC], 2021; CDC, 2021; Arizona Department of Health Services, 2020).
Recommended POCT frequency for screening asymptomatic individuals is 3 times per week of staff, including designated support persons, and residents if the home is in an outbreak situation and once per week of staff and designated support persons in a non-outbreak situation (Ontario Ministry of LTC, 2021; CDC, 2021; Larremore et al., 2020).
Designated support persons (i.e. family caregivers) should be tested at the same frequency as LTC staff (Ontario Ministry of LTC, 2021; Micocci et al., 2020; Vilches et al., 2020; Tennessee Department of Health, 2020).
Recommendations are consistent regarding test interpretation and follow-up actions, with the majority of policies and directives recommending a high degree of caution and follow-up RT-PCR testing after a negative POCT if there is a high pre-test probability for COVID-19 infection (i.e. symptomatic, known contact exposure)(Public Health Canada, 2021; CDC, 2021). All reviewed guidelines recommend confirmatory RT-PCR test following a positive POCT if the individual is asymptomatic in order to avoid unnecessary isolation of residents and work restrictions of staff. Contrary to other guidelines, the Oregon Health Authority (2020) considers all positive antigen tests in a symptomatic individual as a positive test regardless of follow up testing.
Modelling studies consistently show that regular POCT screening of asymptomatic staff and residents in LTC during both outbreak and non-outbreak situations results in significant decreases in projected cases when combined with a multipronged approach to prevent transmission (Larremore et al., 2021; Holmdahl et al., 2020; See et al., 2021; Vilches et al., 2020).
Barriers to frequency of testing are availability of test kits, training of testers, human resources for testing, and a reporting strategy (Micocci et al., 2020).
Prioritization of testing should be given to symptomatic healthcare providers and residents first, then screening for residents and staff during outbreaks (See et al., 2020).
The Saskatchewan Health Authority (SHA) Point of Care COVID Testing: Long Term Care Algorithm contains most of the elements present in other algorithms. Additional information should be added on actions taken for presumptive positive or negative tests in different scenarios. Additional information should be provided on frequency of testing and the context for “high-risk contact”.
Ward, H; Tupper, S; Dalidowicz, M; Mueller, M. What are the efficacies and outcomes of Point-of-Care/Antigen testing in Long Term care? 2021 Feb 26; Document no.: LTC020201 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 37 p. (CEST rapid review report)
· Studies suggest that antigen-based rapid diagnostic tests (Ag-RDTs) can be used in a population level with high prevalence of COVID-19 disease where health systems are overwhelmed or where nucleic acid amplification tests (NAATs) such as real time reverse transcription polymerase chain reaction (rRT-PCR) are not available.
· The Canadian COVID-19 Testing and Screening Expert Advisory Panel recommends the use of frequent screening with rapid diagnostic tests in selected groups to limit outbreaks.
· WHO and European Center for Disease Prevention and Control recommend using Ag-RDTs with high sensitivity and specificity when NAATs are not available or turnaround time negatively affects NAATs’ clinical utility. For example, COVID-19 Ag-RDTs can be used to surveil health care workers or residents of congregate dwellings during outbreaks or when community transmission rates are high, to screen at-risk individuals to support outbreak investigations, or to screen suspected COVID-19 outbreaks in early stages in settings where NAATs are not available.
· WHO does not recommend Ag-RDTs usage when expected prevalence is low (e.g., screening at points of entry) unless an Ag-RDT’s specificity is high (>99%).
· Studies have shown that Panbio™ COVID-19 Ag Test (Abbott) can have overall sensitivity of 72.6% to 95.2% and specificity of 98.0% to 100% and suggest that this test is appropriate for contagious case identification and asymptomatic case screening, especially in high prevalence (>5%) settings.
· WHO recommends that iterative Ag-RDT testing or confirmatory rRT-PCR testing be done in symptomatic patients or asymptomatic contacts of COVID-19 cases since a negative Ag-RDT result cannot completely exclude an active COVID-19 infection.
· Challenges of population level testing (whether they succeed or fail) such as required logistics and resources (e.g., immunizers, access to Ag-RDTs and equipment), performance accuracy of Ag-RDTs (e.g., false positive or negative rates in real world settings), and public trust and engagement in testing and future measures (e.g., vaccine uptake) are yet to be considered.
Vanstone, J; Groot, G; Dalidowicz, M; Fox, L. Are there validated clinical prediction tools of which Covid-19 inpatients are most probable to require ICU level care? 2021 Feb 4; Document no.: EOC012001 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 15 p. (CEST rapid review report)