An associate deputy minister defended the Ontario government's decision to start its vaccination program in hospitals rather than long-term care homes, saying ultra-cold freezers "already existed" in many of them and that hospitals had the ability to "put on these clinics."
Ontario's long-term care commission grilled government officials on Feb. 11 about the province's vaccine rollout in the hard-hit long-term care sector, which stakeholders have criticized as being too slow. One geriatrician said he was "pretty unsatisfied" with the responses provided to the commission.
Despite Quebec launching its vaccination program in long-term care homes in December so residents could be the first to receive the Pfizer-BioNTech vaccine, the long-term care commission heard that Ontario chose the University Health Network in Toronto and the Ottawa Hospital as its first two distribution sites for the Pfizer-BioNTech vaccine during the week of Dec. 14 and expanded delivery to 17 more hospitals the week after.
John Callaghan, the commission's co-lead counsel, started his line of questioning on Feb. 11 by asking why the province didn't move the vaccine once it was received at the first two sites.
He referred to the product monograph dated Dec. 9 that stated the vaccine cartons should be removed from their thermal containers and stored in a freezer at a temperature of between -60 and -80 degrees Celsius. If a freezer wasn't available, the vaccine could be stored temporarily in the thermal containers they arrived in with refills of dry ice. Before being used, the doses would need to be thawed, with Callaghan saying the guidance indicated vials could be stored in a fridge for up to five days.
"Given that your central distribution centres would probably be within about, you know, less than three hours of 90 per cent of people in Ontario, why wasn't that done? That is, ship them out, use them for five days as would be — seems to be provided for in the monograph," said Callaghan, according to a transcript of the testimony.
Alison Blair, associate deputy minister of pandemic response and recovery with the Ministry of Health, stressed that Pfizer's instructions, passed to the province by the federal government's national operations centre for COVID-19 vaccines, was "do not move the vaccines that are delivered beyond the delivery site."
"So how many cold freezers did the province buy?" asked Callaghan, to which Blair said that for the week of Dec. 21, "there were 17 sites that had ultra-cold freezers available to them that received Pfizer."
Callaghan cited a Toronto Star article, which detailed one company that was selling these freezers at a cost of $8,500 and fridges for $14,000, and asked why the province wouldn't have "bought a whole bunch of those fridges."
"We looked at where we had freezers available for delivery ASAP, and we went with the initial 17 in the week of December the 21st, and that was due to availability and also the volume that we were receiving. The decision was made to allocate to places that had the ability to put on these clinics," she said, adding that Pfizer had noted it would deliver to around 100 sites across the country.
She said the priority populations at the hospital vaccination clinics were long-term care staff and essential caregivers.
"The point was to make sure that we were getting to long-term care without being able to move it to long-term care," Blair told the commission. "The ultra-cold freezers already existed in many of the hospitals, and they were chosen as a centralized area that could — that could deal with that, the ultra-cold temperatures and the management of the vaccine, and they had the pharmacy departments to be able to do that. And so that was how the decision was first taken."
She later said the province has put in orders for freezers, and is continuing to do so, but that "some of them are not available until later." The Ministry of Health said it was unable to respond to questions before publication about the province's purchase of ultra-cold freezers and the timing, along with why the province didn't place such freezers into long-term care homes during the initial rollout period.
Dr. Nathan Stall, a geriatrician with the Sinai Health System and the University Health Network, said it seemed as though the decision to bring the vaccines into hospitals first was done almost from a "convenience standpoint."
"There was a short-sightedness in terms of the procurement of the freezers and where they set up the distribution centers," he said. "They could have put some of the freezers within long-term care homes as Quebec did to try and increase the uptake particularly of high-risk, long-term care home residents — that would have also increased the uptake of staff."
Stall said it's clear from the testimony that the government "relied on existing infrastructure without thinking, I would argue, creatively or even innovatively in terms of how they could work within the initial constrictions of the limitations on moving the Pfizer product to maximize the amount of long-term care home residents which were the most vulnerable."
In terms of moving the Pfizer vaccine, Callaghan, seemingly referring to a slide deck, noted that the province received additional information from Pfizer on Dec. 31 about this, to which Blair agreed, noting that the information came through the federal government.
She said the province formed a technical advisory group to develop instructions for the vaccine sites about how to transport doses beyond the location they were first delivered to, with that guidance being issued on Jan. 6. That's also when a pilot was launched, with the Ottawa Hospital being the first to move the Pfizer vaccine to a long-term care home that day.
"So I guess the question is, why would it take you a technical advisory committee in the space of all that five days to come up with recommendations?" asked Callaghan, referring to modelling presented by Stall that showed vaccinating long-term care residents sooner could prevent hundreds of deaths. "It seems like an awfully lot of time in the face of an emergent situation."
Blair said those involved worked to develop the guidance "as quickly as possible ... these are expert pharmacists and technicians who were involved, and they did this as quickly as they could."
The province received around 150,000 doses of COVID-19 vaccines in December, including both the Pfizer and Moderna vaccines. The government announced its plan to vaccinate all residents, health-care workers and essential caregivers at long-term care homes in Toronto, Peel, York and Windsor-Essex by Jan. 21, in early January.
In a Jan. 5 press release, about three weeks after the first Ontarian received a Pfizer shot, the government said more than 50,000 people had received the Pfizer vaccine, but just around 1,000 of those were to residents of seniors' homes. The government said that by Jan. 3, nearly 3,000 doses of the Moderna vaccine were administered in long-term care homes and that another 4,000 were planned up to Jan. 6.
At a Jan. 13 briefing, government officials said 144,000 vaccine doses had been administered in Ontario as of the previous day and that this included 13,000 long-term care and retirement home residents. Another 20,000 residents, staff and essential caregivers at seniors' homes had received the Moderna vaccine, but there was a delay in inputting the information into the province's electronic database due to the use of paper-based reports at these sites.
"Why so few?" asked Callaghan, referring to the 13,000 residents in seniors' homes who were vaccinated.
"My answer to this question is about ... who we were vaccinating with what product starting when," said Blair, noting that on Dec. 31 vaccinations inside long-term care homes in the four hot spots began and that on Jan. 6, hospitals and public health units starting moving Pfizer vaccines into seniors' homes "as quickly as they could."
Callaghan continued to press Blair, saying there was a feeling among some people who testified before the commission that long-term care residents were not prioritized given how few of them were vaccinated by the first couple weeks of January.
He cited an article in the Globe and Mail about a message distributed from University Health Network President Kevin Smith that suggested a directive from Ret. Gen. Rick Hillier was to prioritize "speed over precision" in the province's vaccine rollout.
Blair said she couldn't speak to that specific message, but added that the head of the province's vaccine distribution task force "has certainly been consistent in talking about the need to get vaccinations into the arms of people who need the protection from the virus. And there is no question that he believes that the most vulnerable should be getting those."
She maintained that the province's approach throughout the rollout was protecting the most vulnerable.
But Stall called these "empty words," saying the government only tried to prioritize vulnerable populations "with words and what was on the paper, but not actually when it came to implementation."
"People like me ... who were looking at the data and just being horrified at the slow pace that this was rolling out, we don't really get clear answers as to why we had such a slow pace of rollout," he said. The province, Stall argued, had enough vaccine doses by early January to inoculate all long-term care residents in the province.
"Why did it take another month and a half from that date to get all the long-term care residents done?" he said. "Overall I was pretty unsatisfied with the responses that I reviewed within the testimony."
After twice missing its own deadline to offer a first dose of the COVID-19 vaccine to all long-term care home residents, the government said in a Feb. 14 memo to hospitals and local medical officers of health that it had achieved this target.
Photo credit: Steve Russell/Toronto Star