Author	Reviewer
Christine Palmay, MD, CCFP, FCFP Midtown Health and Wellness Clinic Toronto, ON	Michael Boivin, Rph, CDE Clinical pharmacist consultant and CHE developer, CommPharm Consulting Inc. Barrie, ON.

 

When the WHO declared that COVID-19 was no longer a global public health emergency, I looked blankly at the headlines with a mixed set of emotions. My initial reaction of relief was soon followed by a sense of sadness thinking of all that has transpired during the past year. I was disappointed that there wasn’t a seemingly deserved set of fireworks to mark a triumph and then an ongoing trepidation that such a statement would be universally interpreted as the green light to resume business as usual. Whilst the transition from the clutches of a pandemic to a more manageable state is welcomed, we must remain vigilant. It’s a tough feat, but we must continue to remind patients that although we are tired, COVID is not, and it still poses a real threat. 

 

Ongoing vaccinations are essential for our patients most at risk. Even if the world has been officially granted parole from public health restrictions, COVID still represents a real threat to some of our patients.

 

 

 

Sigh…Yes, it’s “another shot, doc” and yes, “it will like be another shot in the future.”

Patient indifference is mounting and not simply as a result of the WHO declaration. The reality is that we cannot truly track the incidence of COVID cases as patients are not testing and/or not reporting positive infections. Hospitalization statistics no longer make news headlines, thus falsely painting a picture that we are “in the clear” whereas in reality, hospitalizations for older and vulnerable are still significantly higher now than they were during the end of the delta wave in the summer of 2021.

 

What is the latest guidance on COVID-19 booster doses for fall 2023, and how should healthcare providers communicate this to patients?

On a positive note, we have thankfully seen less of an impact of COVID-19 for our younger, healthier patients. As such, NACI has released a new set of guidelines for our COVID 19 SPRING BOOSTER aimed to:

1. encourage healthcare providers to continue having vaccine dialogue with patients.

2. targeting additional doses to patients most at risk for severe COVID-19 outcomes and hospitalization.

 

 

I like to keep things simple.

NACI recommends that a bivalent booster be administered. What about time? NACI currently offers discretionary recommendation that time interval is 6 or more months from the last COVID-19 vaccine dose or SARS-CoV-2 infection if applicable (whichever is longer). Now, in terms of the “who, “I like to think of those patients most at risk and eligible for a COVID-19 booster in 3 categories:

1. Age: Simply stated, the older we are, the higher the risk of severe COVID-19. NACI considers the following age-related risk factors for a COVID-19 spring booster:
• Adults 80 years of age and older
• Adult residents of long-term care homes and other congregate living settings for seniors or those with complex medical care needs
• Adults 65 to 79 years of age, particularly if they do not have a known prior history of SARS-CoV-2 infection or with any comorbidities (as outline below)

2. Comorbidities: Patients with chronic health conditions are at elevated risk of severe COVID-19 outcomes and a SARS-CoV-2 infection may also further worsen their underlying condition. The most important thing to note is that NACI has clearly broadened their inclusion of comorbidities to consider. These are patients who we regularly seen our office and may not self-identify at high risk. The list includes:

• • Cancer
  • Cerebrovascular disease
  • Chronic kidney disease
  • Chronic liver diseases (limited to: cirrhosis, non-alcoholic fatty liver disease, alcoholic liver disease, and autoimmune hepatitis)
  • Chronic lung diseases (limited to: bronchiectasis, chronic obstructive pulmonary disease, interstitial lung disease, pulmonary hypertension, pulmonary embolism)
  • Cystic fibrosis
  • Diabetes mellitus, type 1 and type 2
  • Disabilities (e.g. Down syndrome, learning, intellectual, or developmental disabilities; ADHD; cerebral palsy; congenital disabilities; spinal cord injuries)
  • Heart conditions (e.g., cardiomyopathies, coronary artery disease, heart failure, etc.)
  • HIV infection
  • Mental health disorders (limited to: mood disorders, including depression; schizophrenia spectrum disorders)
  • Obesity
  • Primary immunodeficiency diseases
  • Smoking, current or former
  • Solid organ or blood stem cell transplant
  • Tuberculosis
  • Use of corticosteroids or other immunosuppressive medication

3. Pregnancy: Finally, I include this category for the simple reason that patients often do not consider themselves at risk. A COVID infection during pregnancy can increase the rate of pre-term labour and stillbirth and later pregnancy infections show a higher risk of hospitalization when compared to age matched non pregnant patients. The risk is real and as HCPs we need to educate and advocate for our females during the perinatal period.

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We can obviously all read guidelines (which I encourage you to do), but the success of ongoing COVID-immunization campaigns extends beyond science and truly invokes the art of medicine. Patients, while fatigued, still value our opinions as HCPs and in fact, consider our guidance as the most influential reason why a vaccine is accepted. During our busy clinics, it is important to think of the patients outlined above. These “flags” could be the result of:

1. A clinical encounter – e.g. diabetes check
2. Renewal of medications – e.g. COPD medications
3. A consultation letter from a specialist – e.g. oncology follow-up

In honesty, as primary care providers, I would venture to say that almost every patient encounter represents an opportunity for education. It’s not a dramatic move, nor is it particularly exciting, but there is proven success in consistency and recommendation. Remember the hare and the tortoise….

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While we may be tired (unlike COVID) we can at least steal a good night’s sleep knowing that we have reached out to educate and empower our most vulnerable patients.

Continuing learning with MDLearn webcasts and podcasts:

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The development of this blog was overseen by the Canadian Collaborative Research Network and was supported through an educational grant from Moderna.