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).
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).
· 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)
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)
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)
· Recommended to use existing vaccination structures and delivery services as much as possible for distribution of the COVID-19 vaccines
· Important to consider cold-chain requirements when developing distribution plans
· Should consider alternate locations for hard-to-reach populations that are easily accessible and familiar
· Consider branching out to mobile vaccination (e.g. home visits, door-to-door), pharmacies, workplaces, congregate living facilities, walk-up/drive-through mechanisms for vaccine delivery
Badea, A; Groot, G; Mueller, M; Howell-Spooner, B. How are other jurisdictions distributing COVID-19 vaccines in non-healthcare worker environments and what is the rationale for those distribution models? 2021 Jan 19; Document no.: PH011401 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 17 p. (CEST rapid review report)
Vaccine allocation plans developed using principles based and feasibility frameworks, supported by surveys of healthcare providers and the public are consistent in identifying the following individuals to be prioritized for COVID-19 vaccination (NACI, 2020; CEP, 2020; WHO, 2020; ECDC, 2020; Ismail et al., 2020; ACID, 2020).
oThose at risk of severe illness or death if infected (LTC home residents are consistently identified as a top priority).
oHealth care providers at higher risk of exposure (vaccinate in order to preserve the workforce).
oHealth care providers at risk of transmitting to those at risk of severe illness or death, including health care workers, personal service workers, and designated caregivers.
Within those priorities, additional guidance is given to allocate vaccines to LTC homes in areas with higher community transmission rates, homes with higher resident density and lower staffing levels (Stall et al. 2020), and to residents at higher risk of poor outcomes (advanced age, non-white, male, comorbid illnesses) or at increased risk of transmitting (those with dementia who independently ambulate) (Bell et al., 2020; Ismail et al. 2020).
Feasibility of vaccine storage and transportation will limit implementation of vaccination plans to LTC residents as they may not be able to travel to the vaccination site.
Tupper, S; Ward, H; Miller, L; Mueller, M. What evidence is available to inform immunization (vaccination) planning in long-term care? 2020 Dec 22; Document no.: LTC122101 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 23 p. (CEST rapid review report)
· There is little literature on the performance of triage frameworks. However, critiques of frameworks can help to inform the development of future protocols.
· It is ethically problematic to include age as a triage factor rather than the more nuanced factors of frailty and chronic comorbidities.
· The public should be included when creating triage protocols to create transparency and trust in the health system.
· Healthcare providers should be familiar with the ethical decisions that have been made in establishing the protocols. However, using a triage team to make decisions about resource allocation would alleviate moral burden from clinicians.
· Regular review of current guidelines, such as the use of SOFA scores, is recommended as knowledge about COVID-19 changes.
Rapid Review Report: CC120401 RR (Version 1: December 17, 2020 11:45) 2
· Patients should be regularly reassessed to allow for timely redistribution of critical resources.
Fick, F; Valiani, S; Miller, L; Howell-Spooner, B. Does data exist on the performance of triage or resource allocation frameworks for COVID-19 and other pandemics? 2020 Dec 17; Document no.: CC120401 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 91 p. (CEST rapid review report)
No evidence was found as rationale for the 14-day isolation period on resident transition to LTC. This requirement likely arose from evidence that active monitoring for 14 days is sufficient to identify symptom onset in 99% of COVID-19+ cases (1).
No alternatives were found in Canada to a 14-day isolation period on transition of a resident into LTC. A rapid review of viral shedding and the need for isolation recommends a minimum 10-day isolation period, with additional consideration for high risk groups (36). The Centers for Disease Control and Prevention (2) in the US is considering decreasing the standard 14-day quarantine period to 7-10 days in recognition that the general two-week quarantine rule is onerous for many people and most of the benefit of quarantine to public health could be gained with a more flexible and contextual approach. Implications for changes in Public Health Agency of Canada’s (PHAC) policy on quarantine or duration of isolation for admission to LTC are not yet established.
The Canadian policies at the provincial government levels align with the PHAC’s recommendation of 14 days of isolation (14). Most jurisdictions across Canada follow guidelines requiring a resident to have a negative test on admission, and 14 days of self-isolation with contact and droplet precautions (4, 17).
However, a few jurisdictions stratify the level of precaution or need for isolation by community transmission (3, 5). For example, the Province of Alberta’s (5) Operational and Outbreak Standards for LTC recommends the following safety precaution: for residents with low or unknown risk of exposure, twice daily symptom checks for 14 days; for residents with medium risk, continuous use of a mask for 14 days while out of resident room; for residents with high risk, quarantine for 14 days.
Best practices on transition to LTC to support residents’ well-being
Some Canadian policies state the importance of protecting resident well-being on transition to LTC but provide little guidance on how to ensure this is done. For residents who might find self-isolation challenging (e.g. those with cognitive challenges), Government of New Brunswick (18) recommends taking efforts to ensure adequate staffing level and support residents’ individualized care plan.
Residents in LTC who have cognitive impairments will have difficulties understanding the need for isolation and absence of families and friends, and complying with isolation procedures (31). There is little guidance for long-term care facilities on how to support safe isolation of those living with cognitive impairments, while maintaining the human dignity and personhood of the individual. Strategies need to be developed to have an isolation care planning that is effective, safe, and compassionate (31).
Maintaining connections between residents and their families should be supported under safety, socio-emotional, and ethical grounds (39). Several provinces and international jurisdictions designate Essential Family Caregivers (EFCs), who are present not for social visits but to provide services and brought into the facilities under the same specific protocols as staff (39, 49, 50, 51).
Gao, Y; Ward, H; Tupper, S; Boden, C; Miller, L; Mueller, M. What is the evidence for 14-day isolation upon move-in to long-term care during COVID-19 pandemic? 2020 Dec 13; Document no.: LTC090801 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 33 p. (CEST rapid review report)
No studies directly evaluated the association between level of surge capacity and quality of care indicators for COVID-19 patients. However, in more broad studies, the findings suggest that mortality and other adverse events increase when the strain on the intensive care capacity increases.
A tiered staffing strategy is recommended to meet surge capacity needs in the ICU: High critical care nurse to patient ratios (1:1 or 1:2) are recommended to provide high quality patient care.
There is a lack of high-quality evidence to support ICU triage protocols tailored for patients with COVID-19. Nevertheless, the protocols must be flexible, adaptable according to the availability of local resources, and effective for inter-hospital patient transfer.
While the Crisis Standards of Care (CSC) guidelines (e.g., Saskatchewan’s Critical Care Resource Allocation Framework, published on September 2020) can be used to triage newly admitted COVID-19 patients requiring critical care, there is contradicting evidence about using the Sequential Organ Failure Assessment (SOFA) score for ICU triage of patients with COVID-19.
The literature suggests the use of mathematical modeling to support capacity planning (e.g., very low, low, medium, and high intensity patient surge response)
To relieve pressure from ICUs, other types of units (e.g., Step Down Unit [SDU] or Surge Clinic) can be implemented.
Azizian, A; Valiani, S; Groot, G; Badea, A; Miller, L; Howell-Spooner, B. At what level of surge capacity do quality of care indicators suffer? 2020 Dec 10; Document no.: CC120301 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 17 p. (CEST rapid review report)
No scientific evidence was found to support limits of a specific number of visitors. The Newfoundland/Labrador visitor policy referred to evidence supporting restrictions to 6 contact persons including one designated support person and 5 visitors; however, supporting references were not provided (25; 4.1).
The majority of Canadian and international visitation or family presence policies differentiate between general visitors (those attending for social visits) and designated support persons (essential care providers involved in physical, psychosocial, behavioral, cultural, or language support).
Designated support persons are not limited in duration, timing, or frequency of access to resident (3, 7, 9, 11, 12, 14, 16, 24, 26).
The majority of policies limit the number of general visitors to 2 persons. These visits typically have to be scheduled and may be restricted if there is an outbreak, if the resident is COVID+, or if community transmission is high. General visitors are usually not restricted during end of life or other compassionate care reasons.
Although modeling data supports contact restrictions as an effective measure to reduce infection spread, contact restriction can be achieved with infection prevention and control measures of micro-distancing, including hand and respiratory hygiene, physical distancing, and mask use (49). Family presence in LTC can support efforts to reduce resident wandering, micro-distancing, and hand hygiene.
There continues to be no scientific evidence that family presence increases risk of infection spread into and throughout LTC homes (1, 2, 44, 46)
No evidence was found that examined adherence of family caregivers to IPAC practices. A self-report survey of visitors and staff in 87 LTC homes in Hong Kong found that visitors self-reported high compliance with most infection prevention measures despite only one quarter of homes providing education (50). Low knowledge was identified as a primary barrier for infection prevention for visitors.
Education materials have been developed in several jurisdictions for family caregivers regarding COVID-19 IPAC best practices (4, 6, 8, 28).
No evidence was found regarding the impact of staff or family caregiver education on COVID-19 infection or transmission in LTC homes.
Ward, H; Tupper, S; Miller, L; Boden, C; Mueller, M. What is the evidence regarding limiting patient visitors in long-term care facilities to 2 or less, and how are other jurisdictions managing family caregivers? 2020 Dec 4; Document no.: LTC101501 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 35 p. (CEST rapid review report)
Badea, A; Groot G; Dalidowicz, M; Young, C; Miller, L. What are the recommendations around settling times following aerosol generating procedures on suspected or confirmed COVID-19 patients? 2020 Dec 1; Document no.: EOC081401v2 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 24 p. (CEST rapid review report)
An optimal surveillance strategy for COVID-19 infection in healthcare workers (HCWs) has yet to be determined.
Weekly screening of HCWs for infection through polymerase chain reaction (PCR) testing would reduce their contribution to SARS-CoV-2 transmission by approximately one quarter.
Any testing surveillance strategy should be in addition to other strategies already in place to identify symptomatic HCW.
Any strategy needs to take into consideration the availability of testing (i.e. feasibility) and the level of community transmission (i.e. the risk of asymptomatic HCWs entering the facility and spreading the virus).
HCWs could be categorized as high, medium, or low risk based upon their exposure to COVID-19 and the frequency of surveillance could be designed accordingly.
Newaz, S; Lee, S; Reeder, B; Groot, G; Young, C; Fox, L. What surveillance strategy is most effective for COVID-19 testing in healthcare workers? 2020 Nov 10; Document no.: EOC110401 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 26 p. (CEST rapid review report)
· Well established that older individuals, particularly those with pre-existing conditions are at increased risk of severe disease and/or complications with SARS-CoV-2 infection, and volunteers should take this into consideration
· No other evidence specific to healthcare workers or volunteers to guide age restriction policies
Badea, A; Groot, G; Miller, L; Mueller, M. What are the age restrictions for healthcare workers/volunteer? 2020 Oct 19; Document no.: EOC100801 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 8 p. (CEST rapid review report)
The evidence for alternative active monitoring schedules for confirmed cases of COVID-19 and their cases is limited
The prevailing consensus is that confirmed cases of COVID-19 and their high-risk close contacts should undergo active daily monitoring
When public health resources are limited, active monitoring programs should consider prioritizing vulnerable populations, incorporating passive monitoring practices and adopting virtual monitoring platforms
McLean, M; Groot, G; Dalidowicz, M; Miller, L. Are less frequent (than daily) follow-up/monitoring used in COVID or other communicable diseases? 2020 Oct 6; Document no.:PH092301 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 31 p. (CEST rapid review report)
· The significance of rhinorrhea as a presenting/predictive clinical feature of COVID-19 is unclear at this time with rates ranging from as low as 2% to as high as 60% in the published literature
· Rhinorrhea generally associated with less severe disease
· No reports of sneezing as a clinical symptom of COVID-19
Badea, A; Groot, G; Howell-Spooner, B; Young, C. What is the evidence that runny nose or sneezing are symptoms of COVID-19? 2020 Sep 29; Document no.: EOC092401 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 16 p. (CEST rapid review report)
· The Intubation box was originally invented by Dr. Lai Hsien-yung, an anesthesiologist in Taiwan.
· The main function of the intubation box is intended to prevent exposure of care providers to COVID-19 from aerosol droplets during intubation.
· The intubation box concept emerged during the pandemic to address the challenge of adequate supply of PPEs in resource limited settings in particular but presents limitations and poses significant safety risk to the patient.
· limitations include increased incubation time, discomfort from restricted hand movements for the intubation procedure, reduced first-pass intubation rates, limitation for certain body habitus and possible injury to patient
· With regards to aerosol exposure, intubation boxes have been reported to increase rather than decrease airborne particle exposure.
Asamoah, G; Groot, G; Badea, A; Ellsworth, C; Fox, L. What are the safety risks or disinfection concerns with the use of intubation boxes? 2020 Sep 8; Document no.: EOC090202 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 13 p. (CEST rapid review report)
· Infrared thermometers detect the infrared waves emitted by an object and convert into an electrical signal to display the distribution of temperature
· Infrared thermometers do not emit radiation, however many are equipped with a laser tracker beam, similar to that found in television remote controls
· The Pineal Gland is located deep inside the brain, separated from the forehead by the presence of the skull and several centimeters of brain tissue
Badea, A; Groot, G; Ellsworth, C; Fox, L. Is there evidence of risks for using infrared thermometers? 2020 Aug 29; Document no.: EOC082502 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 12 p. (CEST rapid review report)