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09/22/2021

COVID-19 boosters: why aren’t doctors allowed to protect their most vulnerable patients?

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Woman with brown skin and grey hair sitting looking at the camera
Dr. Mary Fernando

The Ontario government recently stated, “Third doses are being offered to specific high-risk groups to help provide sufficient protection based on a suboptimal or waning immune response to vaccines and increased risk of COVID-19 infection.”1

As the publisher/owner and a reporter of Blacklock’s, Holly Doan has worked throughout the pandemic while being on an immunosuppressive drug for an autoimmune disease.

“Originally the department of health said that family doctors would be able to decide who should get the vaccines. Family doctors know their patients better than anyone else,” she says. 

“When I needed to get an accelerated second shot, Ottawa Public Health gave it to me because I had a note from my family doctor.

Read: QUIZ: What do you know about COVID booster shots?

“More recently I went to public health to ask about COVID-19 boosters. They told me that I don’t qualify . . . because my immunosuppressive drug wasn’t on the list. I trust my doctor more than I trust an administrator who appeared to not even know my drug. 

“So what’s happening? Why are family doctors not part of the decisions? Is it politics? I don’t have the answers but it seems like a big mix-up.” 

In all fairness, the guidelines are needed and are set by experts. The question isn’t whether we should have guidelines for COVID-19 boosters—of course we should. The question is whether doctors—who are experts on their patients and assessing who is immunocompromised—should have some ability to advocate for their most vulnerable patients. And should administrators without medical knowledge be the gatekeepers of these boosters?

Read: WHO chief urges halt to booster shots for rest of the year

Dr. Jennifer Kwan echoes Holly Doan’s comments on doctors, “As a family physician, I know my patients’ history in great detail. Not just their personal medical history, [but also] their social history, risk factors from family, if they have higher risk workplaces or vulnerable family members at home. 

“We rely on guidance by provincial leadership to help make decisions, but sometimes the rules take some time to change given the new evidence.”

An excellent example of this, Dr. Kwan points out, is that community seniors aren’t eligible for boosters. 

The Ontario government is only giving residents of long-term care and retirement homes boosters and states, “Evidence shows that several months after receiving two COVID-19 vaccine doses, the immune response in residents who live in long-term care homes wanes significantly compared to the general population."1

This paints an incomplete picture because the scientific evidence points to age causing waning immunity, “older individuals given a third dose of vaccine were less likely to become infected and much less likely to develop severe disease than those who had not received the boosters.”2

Community seniors often live in condos, breathing air shared with other condos that may house people infected with COVID-19. They ride elevators and either shop for themselves or have multiple caregivers. In short: they have multiple risk factors including age and there is no medical reason to exclude them from booster shots. 

Read: Head of UN health agency seeks vaccine booster moratorium

Dr. Kwan thinks that the provincial guidance is too restrictive. “There should be reasonable exceptions where physicians can make decisions for their vulnerable patients. [Presently] if I have extra doses at the end of the day, I can’t give them to patients I’ve assessed as vulnerable. I have to throw those doses in the garbage. I’d rather give them to community seniors rather than throw them out."

So, these restrictive rules that don’t allow doctors to use their expertise is resulting in vaccine wastage.

Dr. Christopher Leighton, an adjunct professor of Oncology at Western, echoes Dr. Kwan’s assessment that the guidelines are useful but doctors should also be allowed to use their clinical judgement. “I can understand population based decisions on the first round of vaccinations. I wasn’t happy with some of the exclusions [for early vaccines] but they eventually got there. We’re moving into a new phase with these boosters and the next round that may come. Now family physicians should be included and, I don’t see why, for example, immunologists don’t receive a certain number of doses for their patients.”

Certainly immunologists—who are the experts treating immunocompromised patients—should be able to give their immunocompromised patients COVID-19 vaccines. They are the experts in assessing who is actually immunocompromised.

Dr. Leighton also feels that oncologists should be able to request boosters for their most vulnerable cancer patients. 

Read: Canada secures millions of vaccine booster shots from Pfizer for future: Trudeau

There will likely be more rounds of COVID-19 vaccines—hopefully some that target the variants. Will doctors continue to be sidelined in decisions that impact their patients? Will patients be left to deal only with administrative gatekeepers, without their doctors able to give or advocate for them getting vaccines if they are at risk? If some who are immunocompromised, like the community elderly, patients on certain drugs or with certain illnesses, are refused the booster and contract the virus, who is accountable for the illness and death that may result? 

Have we entered an era where patients have life and death decisions made for them by people who don’t know them, don’t have medical expertise, only read a list and aren’t responsible in any way for the precious lives they impact?

Maybe the government should give doctors—who know their patients and put their licences on the line with every medical decision they make—some ability to ensure their most vulnerable patients get boosters, and at least give the boosters that would be otherwise thrown out.

As we enter the very dangerous fourth wave of this pandemic, it’s unfair to leave patients without their doctor in their corner, who knows their medical history, cares about them and is willing to put their professional career on the line every time they provide them with care. That, in a nutshell, is the difference between administrators, who are now the gatekeepers for the vaccines, and doctors who are not. 

The province has made these rules and they need to explain why they aren’t allowing patients to be protected by their doctors. With the Delta variant surging in Ontario, this is not the time to ignore the doctors of vulnerable patients. Surely, by now, we’ve learned there is a price to be paid for ignoring medical expertise during a pandemic.

Dr. Mary Fernando is a physician in Ottawa.

References: 

1. Expanded Eligibility for Third Doses of the COVID-19 Vaccine

2. COVID vaccine immunity is waning — how much does that matter?

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