Category: Medicine Hat News

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What do we know about COVID-19 vaccine booster shots?

A mosque in Cairo, Egypt. (Dr. Noorali Bharwani)
A mosque in Cairo, Egypt. (Dr. Noorali Bharwani)

Like many of you, I am curious to know what kind of protection am I getting after third and fourth dose of COVID-19 vaccine.

Is it necessary to have third and fourth dose?

What is meant by “fully vaccinated” against COVID-19?

How many vaccine doses do we need to remain protected against COVID-19?

As you may know, some medical conditions, such as measles or polio, completing the primary vaccination series usually provides lifelong protection against disease. For others, such as tetanus, diphtheria, and pertussis, periodic booster doses of vaccine are required.

With COVID-19 we have learnt levels of protection begin to wane over time, resulting in breakthrough infections. Breakthrough infection is usually not serious.

Many experts believe people are “fully vaccinated” either two weeks after they receive their second dose in a two-dose series, or two weeks after their first dose for single-dose vaccines.

However, “fully vaccinated” is not the same as “optimally protected”, says CDC (US Center for Disease Control and Prevention). “To be optimally protected, a person needs to get a booster shot when and if eligible.”

We know one- or two-dose series remains extremely effective at preventing severe infection and death. How can we maintain this level of protection?

On 30 March, 2022 the CDC recommended a fourth dose of COVID-19 vaccine for everyone over 50 years of age.

No vaccine is 100 per cent effective. Breakthrough infections can happen with every vaccine, and do not mean that the vaccine does not work.

According to data from the US CDC, unvaccinated people are at 11 times the risk of death from COVID-19 than vaccinated people.

WHO (World Health Organisation) says, “Even once you are fully vaccinated, continue to practice the same prevention measures to protect yourself. Stay at least one metre away from other people, wear a well fitted mask over your nose and mouth when you can’t keep this distance, avoid poorly ventilated places and settings, clean your hands frequently, stay home if unwell and get tested.”

Why do we need booster dose?

The protection you get from COVID-19 vaccines can wane over time (4-6 months); so, booster doses are necessary. Boosters can help improve protection against severe outcomes by up to 90 per cent. They may also reduce the risk of post COVID-19 condition.

Many Canadians are reluctant to go for booster shots (third and fourth shot). According to an article in the Canadian Medical Association Journal (CMAJ April 11, 2022) only 56 per cent of adults, and far fewer children, have received three doses of a SARS-COV-2 vaccine. Meanwhile, vaccine manufacturers are warning that fourth doses may be necessary to maintain immunity.

Third dose is 95 per cent effective against hospitalization and death. It also brings vaccine efficacy to 97 per cent for Delta and 61 per cent for Omicron. However, it’s unclear how long good protection from a third shot will last.

Is fourth vaccine dose necessary?

Canada’s National Advisory Committee on Immunization currently recommends four doses for people who are immunocompromised, but most provinces are also offering fourth shots to seniors. Both groups may face increased risks of severe illness and greater declines in vaccine efficacy than the general population. Otherwise, experts remain divided on the value of repeat boosters.

Some argue the goal of vaccination should be to prevent severe disease and deaths, not infections, so three shots may be sufficient for most people so long as efficacy against hospitalizations holds, says CMAJ article.

Others argue it makes more sense to focus on distributing vaccines globally and developing new variant-specific vaccines rather than repeatedly using the same shots in a few wealthy countries, with diminishing returns. The evidence to support four doses is limited.

So, what do you think? Is fourth dose necessary?

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Facing the End of Life Cannot Be Easy

An Owl in the Dubai Desert. (Dr. Noorali Bharwani)
An Owl in the Dubai Desert. (Dr. Noorali Bharwani)

Right now, I know three individuals who are terminally ill. Two are my close friends and one is a close relative. I have known them for many years. It is hard to write how I feel about this.

Sometimes, I wonder, why some people die suddenly (like my dad, brother and sister died) or die from a terminal illness that can go on for weeks and months (like my mom, and other sister died).

I am pretty sure everybody has thought about how they would like to die. There are pros and cons to sudden death versus prolonged death. Now Canadians with incurable illness have a third option called medical assistance in dying (MAID).

Dying is part of life. Dying with dignity is everybody’s desire. Some are afraid to die because we don’t know what it feels like or what will happen once our heart stops beating and we stop breathing.

Is it possible to die with dignity? There are many end-of-life care options. For example: palliative care in an institution, do not resuscitate orders, refusal or withdrawal of treatment, palliative sedation to ensure comfort and finally MAID.

Before we discuss medical assistance in dying (MAID), I would like to mention one name – Dr. Jack Kevorkian (1928 – 2011). He was an American pathologist and euthanasia proponent, who gained international attention through his assistance in the death of more than 100 patients, who were terminally ill.

He publicly championed a terminal patient’s right to die with physician’s assistance, embodied in his quote, “Dying is not a crime”. He was convicted of murder in 1999 and was often portrayed in the media with the name of “Dr. Death”. There was support for his cause, and he helped set the platform for reform. He spent eight years in jail for assisting a patient with Lou Gehrig’s disease to die.

It has taken almost 30 years for Dr. Kevorkian’s dream come true.

According to Health Canada website, on March 17, 2021, the Government of Canada announced changes to Canada’s MAID law. The new law includes changes to eligibility, procedural safeguards, and the framework for the federal government’s data collection and reporting regime.

The law clearly defines who may be eligible to obtain MAID and the process of assessment. The law ensures eligible Canadians will be able to request MAID according to the new law, and that the appropriate protections are in place.

Physicians and nurse practitioners can legally provide MAID.

Pharmacists, health care providers and family members can legally help. These people can assist in the process without being charged under criminal law. The federal legislation does not force any person to provide or help to provide MAID if it is against their religious or other beliefs.

There are two types of MAID available to Canadians. They each include a physician or nurse practitioner who directly administers a substance that causes death. Second option is known as self-administered MAID. A doctor can provide or prescribe a drug that the eligible person takes, in order to bring about their own death.

Several conditions have to be met to be eligible for MAID. A person should be at least 18-years-old and mentally competent. Should have a grievous and irremediable medical condition, make a voluntary request for MAID that is not the result of outside pressure or influence, and give informed consent to receive MAID.

We know one day we are going to die. To die with dignity is the best way to go. How do we prepare for that? There are no simple answers. As Woody Allen said, “I am not afraid of death. I just don’t want to be there when it happens.”

I wish you all good health, happy times with long life.

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Unexplained shortness of breath should be investigated urgently.

Sunset in Drumheller. (Dr. Noorali Bharwani)
Sunset in Drumheller. (Dr. Noorali Bharwani)

Recently, a relative of mine died. She had shortness of breath. She went to ER and was admitted to a hospital. She was investigated. After a week of investigations, she underwent coronary angioplasty for a narrow coronary artery. Two days later she was discharged. She went home and within an hour she fainted and died. That was sudden and tragic.

Statistics show one in 20 patients with unexplained shortness of breath in the primary care setting will have heart failure as its cause.

Statistics also show 38 per cent of patients with unexplained shortness of breath do not receive a definitive diagnosis within six months post-referral.

When a person presents with shortness of breath, the clinician has to determine whether it is due to cardiac (heart failure) or pulmonary cause.

Heart failure – also known as congestive heart failure – occurs when the heart muscle doesn’t pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.

What causes heart failure?

Common causes of heart failure are coronary artery disease, heart valve disease, high blood pressure and cardiomyopathy. If you’ve been diagnosed with one of these conditions, it’s critical that you manage it carefully to help prevent the onset of heart failure.

How would you know you are in heart failure?

Swelling of the feet and ankles, shortness of breath, fatigue, abdominal fullness due to swelling and distention of the liver are early manifestation of heart failure.

If you have these symptoms, you should see your doctor immediately. The doctor will order investigations which will include: blood tests, chest x-ray, echocardiogram, stress test, CT scan, MRI, coronary angiogram etc.

Some doctors rely mostly on NT-proBNP testing to monitor patients with heart failure. You do not need to fast or do anything to prepare for the test. Levels go up when heart failure develops or gets worse, and levels go down when heart failure is stable. In most cases, BNP and NT-proBNP levels are higher in patients with heart failure than people who have normal heart function.

The result helps your doctor determine if you have heart failure, if worsening fatigue or shortness of breath are due to heart failure or another problem or if heart failure has progressed toward end-of-life. It is important to note that this test is only one method your doctor uses to monitor your condition. Based on your results, your doctor can choose the best treatment plan for you.

Sixty-seven per cent of patients with unexplained shortness of breath did not need further diagnostic work-up after taking NT-proBNP test. A very useful test for patients with chronic unexplained shortness of breath.

The Canadian Cardiovascular Society recommends NT-proBNP screening to help confirm or rule out heart failure in patients with shortness of breath when clinical diagnosis remains uncertain. This can aid in decision-making and accelerate the pathway to appropriate referral.

In Alberta, Laboratory Services has offered B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) testing in hospital laboratories across the province since 2012. Emergency Department physicians and cardiologists are able to order these tests to assist with diagnosing and treating heart failure. This test has improved quality of referrals to cardiologists and has reduced diagnostic delays.

Treatment for heart failure:

For most people, heart failure is a long-term condition that can’t be cured. But treatment can help keep the symptoms under control, possibly for many years.

The main treatments are: healthy lifestyle changes, medications, devices implanted in your chest to control your heart rhythm, and surgery. Treatment will usually need to continue for the rest of your life.

The life expectancy for congestive heart failure depends on the cause of heart failure, its severity, and other underlying medical conditions. In general, about half of all people diagnosed with congestive heart failure will survive five years. About 30 per cent will survive for 10 years.

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Outpatient Treatment for COVID-19 Infection

Saskatoon Farm, Foothills County, Alberta. (Dr. Noorali Bharwani)
Saskatoon Farm, Foothills County, Alberta. (Dr. Noorali Bharwani)

According to Reuters, global COVID-19 cases have surpassed 500 million, as the highly contagious BA.2 sub-variant of Omicron surges in many countries in Europe and Asia and North America.

Recent surge across Canada has been driven by the Omicron variant and its BA.2 subvariant.

In Alberta and rest of Canada, COVID-19 numbers are going up as we relax on our need to wear a mask, avoid crowded gatherings and get fully vaccinated. Wearing a mask is strongly recommended by Canada’s Chief Medical Officer of Health.

In order to prevent hospital overcrowding with COVID-19 infected patients, Health Canada has approved out-patient use of medications for certain group of venerable individuals who are infected. Since these medications are currently in short supply, Health Canada has advised provinces to prioritise patients as follows:

  1. Individuals who have the highest likelihood of severe illness including those who are immunocompromised regardless of vaccination status;
  2. Individuals over the age of 80 whose vaccinations are not up to date; and
  3. Canadians aged 60 or older who live in underserved rural or remote communities, long-term care homes, who are from First Nations, Inuit, and Metis communities, or whose vaccinations are not up to date.

Alberta Health Services and Alberta Health are rolling out the administration of outpatient treatments like Paxlovid™ and Remdesivir, COVID-19 medications recently approved by Health Canada that are shown to prevent COVID-19 from progressing in high-risk patients with mild to moderate symptoms if taken within five days of symptom onset (seven days for Remdesivir), says Alberta Health website.

Patient will be first assessed by a healthcare professional before Paxlovid or Remdesivir will be available to the patient.

Paxlovid is taken orally in pill form. One dose is a combination of two nirmatrelvir (pink) tablets and one ritonavir (white) tablet, taken twice a day for five days. Patients with a reduced kidney function may have their dose reduced to two pills twice a day for five days.

Remdesivir is given intravenously by a qualified health professional. The medicine is given over 30 minutes. You will be watched closely for another 15 to 30 minutes after getting the treatment. You can expect the appointment to last about 1.5 hours, including setup time.

In Alberta, Who Is Eligible for Paxlovid and Remdesivir?

Treatments are available for patients who have a lab-confirmed COVID-19 infection if they can receive the treatment within five days of symptom onset for Paxlovid or seven days for Remdesivir and they are:

  1. Unvaccinated or have received one dose of a COVID-19 vaccine and are: age 55 and older or Indigenous, and age 45 or older or age 18 and older with a pre-existing health condition including diabetes (taking medication for treatment), obesity (BMI >30), chronic kidney disease (estimated glomerular filtration rate, <60 ml per minute per 1.73 m2 of body-surface area), congestive heart failure (New York Heart Association class II, III, or IV), chronic obstructive pulmonary disease, and moderate-to-severe asthma, pregnant OR
  2. Immunocompromised (vaccinated or unvaccinated), due to reasons including but not limited to: have received a transplant, is an oncology patient who has received a dose of any intravenous or oral chemotherapy or other immunosuppressive treatment since December 2020, has an inflammatory condition (e.g., rheumatoid arthritis, lupus, inflammatory bowel disease) receiving a dose of any systemic immunosuppressive treatment since December 2020 OR
  3. Living in long-term care or designated supportive living, regardless of age or vaccine status.

How do you access Paxlovid or Remdesivir?

If you have tested positive for COVID-19 and your symptoms began less than four days ago and you believe you meet the eligibility criteria (above), please call the dedicated Health Link line at 1-844-343-0971 to find out if you qualify to receive treatment. Do not call 811, says Alberta Health website (Outpatient Treatment for COVID-19). The website also has more information.

Remember 10 words: Wear a mask, avoid crowded gatherings and get fully vaccinated.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!