Why provinces and territories jump the gun on Canadas COVID-19 vaccine guidance

This is an excerpt from Second Opinion, a weekly roundup of health and medical science news emailed to subscribers every Saturday morning. If you haven't subscribed yet, you can do that by clicking here.

Canada's vaccine advisory committee has given advice that's repeatedly been proven right throughout the pandemic â€" in the face of limited data and vocal criticism â€" and saved lives.

But multiple medical experts say the failure to do so quickly and transparently threatens to undermine public confidence on key vaccine issues and forces provinces to make crucial decisions on their own.

The National Advisory Committee on Immunization (NACI) released new guidelines on booster shots Friday â€" after weeks of deliberation â€" strongly recommending them for those over 80 and leaving the door open to others at risk of lowered vaccine protection.

But the NACI recommendations came after a handful of provinces and territories across Canada already announced their own plans for booster shots, calling into question the speed in which the committee can react to emerging evidence and issue national advice.

"It's fair to say that NACI has come up with some excellent recommendations," said Dr. Isaac Bogoch, an infectious diseases physician and member of Ontario's COVID-19 vaccine task force.

"But it would be very helpful to have these recommendations faster." 

Provinces, territories 'jump the gun' on NACI

B.C. pre-empted NACI on Tuesday, rather than wait any longer for the committee's highly anticipated guidance to be released, announcing its own plan to roll out boosters for everyone in the province by May 2022 that goes far beyond the committee's approach.

Provincial Health Officer Dr. Bonnie Henry said in a phone interview the reason B.C.'s booster guidance came days earlier than NACI's is because she wanted the province to have a "simple, longer term strategy that people will understand." 

"What we're seeing now on the ground here is breakthrough [infections] in the older people who went first," she said. "So that's why we needed to be more proactive to try to get out booster doses to those people right away."

WATCH | Breakthrough COVID-19 infections cause confusion, concern:

Breakthrough COVID-19 cases bring confusion, concern19 days agoThey only account for roughly 30 per cent of COVID-19 cases, but breakthrough infections are happening. The situation is confusing to the fully vaccinated who got the virus, and experts say the cases may be a worrisome signal. 4:13

The Northwest Territories offered boosters to everyone over the age of 18 on Thursday, and the Yukon will soon make them available to those over 50. Saskatchewan expanded boosters to Indigenous people over 50 and anyone over 65 and Alberta did the same for Indigenous people over 65 and anyone 75 or older earlier this month.

But this isn't the first time NACI has been beaten to the punch. 

NACI previously recommended third doses for severely immunocompromised people who don't generate strong initial responses to the vaccine â€" a different matter than booster shots that top up declining antibody levels â€" but even that guidance was pre-empted by some provinces. 

Ontario and Alberta began offering third shots for certain vulnerable groups including transplant recipients, cancer patients, immunocompromised individuals and long-term care residents weeks before NACI's guidance finally came out in mid-September. 

And Quebec and British Columbia previously leapfrogged NACI's guidance on delaying second doses and mixing and matching COVID-19 vaccines â€" opting to instead to release their own strategy rather than wait for the committee to act. 

Bogoch says there's "no reason" why NACI shouldn't be able to release recommendations sooner, but they need more resources to stay on top of emerging data and to avoid  "bureaucratic hurdles." (It can take NACI a week to translate and upload its guidance online.)

"It would be very helpful if they had additional support, so that they can continue to do the excellent work that they do in a timely manner," said Bogoch.  

"That way, you could avoid having provinces jump the gun and we can avoid a situation where we have 10 provinces and three territories doing things differently." 

Lack of transparency ahead of 'hot-button issues' 

Another key area experts say NACI is falling behind on is transparent, open communication with Canadians and the media â€" especially as guidelines for sensitive topics like COVID-19 vaccines for children are expected to be released in the coming weeks.  

Unlike the U.S., where vaccine advisory committee meetings on key issues like booster shots and vaccines for kids are live-streamed online with questions from the public addressed, NACI meetings are held behind closed doors without public input. 

Helen Branswell, an infectious diseases journalist with STAT, said the U.S. approach of holding advisory committee meetings in public helps journalists and the public "understand what the concerns are" and "the thinking behind the decisions that are being made." 

NACI also hasn't held a press conference or taken questions directly from the media in months, since the departure of outspoken former NACI Chair Dr. Caroline Quach, and now opts for federal government spokespeople to comment on their guidance.

"It's absolutely possible to have a more open process, but I think that people were not ready to try that in the middle of a pandemic," Quach said in a phone interview.

"After the pandemic it's possible that something more open will come, but it's just that changing everything in the middle of a crisis is never the best idea." 

NACI hasn't held a press conference or taken questions directly from the media in months, since the departure of former NACI chair Dr. Caroline Quach, and now opts for federal government spokespeople to comment on their guidance. (Marc-André Lapierre)

But the independent advisory committee did ultimately opt to change its communication strategy in the middle of the pandemic â€" making it less accessible to the media, and less visible to the public as a result. 

The Public Health Agency of Canada (PHAC) has since taken over all of NACI's media duties, with interview requests and questions for NACI forwarded directly to PHAC media relations staff and press briefings held by Dr. Theresa Tam and Dr. Howard Njoo on NACI's behalf. 

"In principle, I have no problem with the decision to pass the communications mandate back to PHAC," said Dr. David Naylor, who led the federal inquiry into Canada's national response to the 2003 SARS epidemic and now co-chairs the federal government's COVID-19 immunity task force. 

"In practice, however, I don't think this approach is working optimally. And that's a worry because we have some hot-button issues coming up fast." 

Dr. David Naylor says there are 'strong feelings' on upcoming issues like vaccines for children and booster shots for the broader Canadian public, in addition to 'gaps in the evidence' that could lead to a 'very polarized debate.' (Jae C. Hong/Associated Press)

Naylor says there are "strong feelings" on upcoming issues like vaccines for children and booster shots for the broader Canadian public, in addition to "gaps in the evidence" that could lead to a "very polarized debate."

"Whoever handles the communication on these fronts in the next few days and weeks needs to be fully committed and well prepared."

WATCH | How communities work to get parents on board with COVID-19 vaccines for kids:

Communities work to get parents on board with COVID-19 vaccines for kids3 days agoCommunity groups are using some of the lessons they learned in overcoming COVID-19 vaccine hesitancy in adults to help parents on board with vaccinating their children. 2:05 Public spotlight 'not sustainable' for NACI

NACI is now far less open to discussing and explaining the reasoning behind its recommendations with the press and the public than it has been in the past â€" and that may be in part due to a change in leadership.

Unlike Quach, who is a professor of infectious diseases, immunology, microbiology  and pediatrics at the University of Montreal with a somewhat flexible schedule, current chair Dr. Shelley Deeks is also Nova Scotia's public health surveillance medical officer of health.

"Vaccines have been politicized at times," said Naylor. "And it's possible that one factor in the change is that having a very senior provincial official as chief spokesperson for a federal panel could be a bit awkward at times." 

A woman receives a booster dose of the Pfizer-BioNTech COVID-19 vaccine at Skippack Pharmacy in Schwenksville, Penn., on Aug. 14. (Hannah Beier/Reuters)

Quach says that once Deeks took over the role as NACI chair, the two of them agreed that keeping up the previous level of public press conferences and media interviews was "not sustainable." 

"That flexibility wasn't there anymore and so that's really when NACI asked the Public Health Agency of Canada to take back all the press, all the communications," Quach said. 

"I like giving media interviews â€" I don't think Dr. Deeks likes it that much â€" and you can't force her. She's doing an amazing job as a chair of the committee but being a spokesperson was not part of her job description when she signed up for it." 

When asked by CBC News why questions from the press must now be forwarded to PHAC, instead of being answered directly by the NACI chair like the many times it had done so in the past, Deeks responded by forwarding the question to PHAC.

A spokesperson for PHAC said the interest from the general public and the media in the "rationale, data and evidence" of NACI's recommendations has increased throughout the pandemic, which is why NACI began participating in press briefings in the first place. 

"However, NACI is a committee that is comprised of volunteers whose time is very limited during a pandemic response," the PHAC spokesperson said. 

"In order to allow NACI to focus on its important deliberations and advice to public health decision-makers and healthcare providers, PHAC is responsible for conveying this advice to the Canadian public and media." 

Sabina Vohra-Miller, a pharmacologist and science communicator who co-founded Unambiguous Science and the South Asian Health Network, says NACI could benefit from a communications expert who could convey its recommendations to the public in a clear-cut way. 

"The kind of support they need is not silencing them. I don't think their voice should be silenced. They have a very strong, very needed voice here in Canada," she said. 

"We need to have that trustworthy, consistent voice speaking to the public. And frankly, I haven't even seen that coming from the Public Health Agency of Canada either." 

WATCH | PHAC says booster shots not needed for general population yet:

Tam says COVID-19 booster shot not required for general population right nowDr. Theresa Tam, Canada's chief public health officer, says there is no evidence at this time of any widespread reduction in protection for those who have received their COVID-19 vaccines. 2:04

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