TORONTO -- The first sign of an end to the coronavirus pandemic is here as vaccines circulate around the country, but much remains unclear.

The Pfizer-BioNTech vaccine was the first to circulate​ among priority groups, but won't be the last. While Health Canada could be close to approving additional coronavirus shots for use in Canada, whether they will mean a return to normal remains to be seen. Meanwhile, the latest federal modelling data suggests the second wave of the pandemic could get worse long before most of the country is vaccinated.

CTVNews.ca readers submitted their burning questions about COVID-19 immunization and we posed them to infectious disease experts Drs. Isaac Bogoch, Zain Chagla, Sumon Chakrabarti, Anna Banerji and Marla Shapiro. Here’s what they said. Note: Questions have been edited and condensed for clarity.

 

It is free. The federal government expects to be able to offer free vaccination to all Canadians. Health officials have procured the most doses per capita for Canadians than any other country, but are also committed to supplying vaccines to low- and middle-income countries who weren’t able to order doses.

The Canadian government assembled a team of experts and officials months ago to prepare for vaccine rollout, including logistics and prioritization. From an operations standpoint, a Canadian military general is heading the rollout. From a prioritization standpoint, the National Advisory Committee on Immunization (NACI), a long-established body that includes public health, infectious disease, and immunization policy experts, created a vaccine prioritization framework, released in early November. The framework determined that people and staff at long-term care facilities should be immunized first, then other health care workers and vulnerable populations, and finally the general population.

It’s possible that vaccination could be required in certain education, health care and travel circumstances, said Chagla, and there is precedent for it.

In parts of South America and Africa, travellers are required to present a “yellow fever vaccination certificate” to prove they are immune from the virus and won’t set off an outbreak. In Canadian schools, some provinces require children and adolescents to be immunized from a variety of illnesses before they can attend school, unless they have a medical exemption.

“I think you’re going to see some fairly forward-facing industries like travel industries, health care, schools, where this is probably going to be part of the mandate,” said Chagla, noting that mandatory vaccinations get “dicey” when it comes to employment law.

While no one can be forced to get an eventual COVID-19 vaccine, ethicists have urged for more clarity around what the rollout of vaccines will mean, including for millions of people who may choose not to get one.

“That is an ethical concern because what will likely happen to people within that group is more and more opportunities may slowly be shut off to them,” Kerry Bowman, a bioethicist and assistant professor at the University of Toronto’s faculty of medicine, told CTV National News.

Common side-effects will have already been identified since most adverse events associated with vaccines occur within a day of receiving the shot, said Bogoch, the most common of which is a sore arm.

“There are certain rare vaccine side effects that can occur two to four weeks after vaccination. They’re not very common at all,” he said, adding that early data suggests the Pfizer and Moderna vaccine candidates, which use a relatively new mRNA technology, have not resulted in any notable side effects other than people feeling “fatigued or a little unwell” in the day following vaccination.

No. The vaccine is preventative, not therapeutic. Someone with COVID-19 should remain isolated until full recovery and later seek vaccination. “The recommendation is typically about 90 days or longer after an onset of the coronavirus to get the vaccine to offer longer-term immunity,” Shapiro told CTV News Channel. “It would act as a typical vaccine does for future forward immunity.”

No. The federal and provincial governments are not implementing widespread routine screening before vaccinating individuals. “That would not be cost-effective,” Shapiro told CTV News Channel. Instead, health officials developed a prioritization framework to determine who gets vaccinated first. “You would be getting the vaccine regardless, as long as you’re [part of the group] that’s stratified.”

Yes. While research shows that COVID-19 antibodies are often detectable several months after infection, there have been several reports of reinfection.

“We know that those credible cases of reinfection are pretty much the tip of the iceberg,” Bogoch told CTV’s Your Morning. “It’s probably happening a lot more frequently than we would think.”

There has been no evidence of “sterilizing immunity,” adds Shapiro, meaning we can’t say if anyone infected with COVID-19 will be “immune for life.” Whether or not you have COVID-19 antibodies from past infection, the vaccine is still recommended, she told CTV News Channel.

It’s likely that the majority of people with allergies will be able to receive the Pfizer-BioNTech vaccine and others, but experts stress that Canadians should go over the list of ingredients with their physician. On Dec. 12, Health Canada issued a notice that people with severe allergies to the ingredients in the Pfizer product should avoid the shot altogether.

“If you’re allergic to any of those ingredients you shouldn’t be getting this vaccine and luckily we have other vaccines that are in the pipeline and are hopefully going to be available in Canada soon,” Bogoch told CTV’s Your Morning.

Yes. Guillain Barre syndrome is an uncommon condition in which someone’s immune system attacks their nerves and can result in weakness, tingling and paralysis. “It’s a rare event. Most of the time people don’t know why Guillain-Barre happens, but it’s not something that usually happens on a repetitive basis,” said Banerji. "Someone who's had Guillain-Barre, if they have any underlying conditions, [those conditions] may make them at risk for severe COVID-19 infection. If someone's at risk of severe disease from the virus, they should get the vaccine."

The messenger RNA vaccine by Pfizer-BioNTech does not contain preservatives. Mercury-based preservatives like thimerosal, which researchers have shown is safe in low doses and does not cause autism, have not been used in the majority of vaccines since the late 90s.

The Pfizer and Moderna vaccines are both “messenger RNA” or mRNA vaccines, which is a new kind of vaccine technology that is like “giving an instruction booklet for your cells to make antigens,” said Chakrabarti in a phone interview with CTVNews.ca last month. In the absence of the coronavirus, a person’s cells would still be programmed to develop the antibodies that fight the virus off.

The AstraZeneca vaccine, developed by Oxford University scientists in England, uses a more well-established approach that introduces a cold virus common in chimpanzees. The vaccine alters the chimp virus, called a modified adenovirus vector, to mimic COVID-19 and thereby produce an immune response in the human body.

Probably not. While study participants represented a wide spectrum of ages and ethnicities, they were also all generally healthy people, said Chagla in a phone interview with CTVNews.ca in November. In the past, when vaccines for other illnesses rolled out, they may have had strong data from clinical trials too. “But they’re not necessarily as good as patients get more complex, as their medications get more complex and their immune system diseases are more complex,” he said, so defining the efficacy of a vaccine after rollout becomes a difficult task. “More surveillance, more data, once it comes to the market, will probably tell us what the real life efficacy of these vaccines are,” he said. “I would suggest it will probably be a little less than this 95 per cent.”

It’s too early to know. The Pfizer and Moderna vaccines require two doses, separated by two weeks, but the second is not considered a “booster” shot, which are given to prevent immunity from waning.

“We don’t have a clue how long immunity will last,” said Bogoch over the phone with CTVNews.ca in November. “We’ll have clues about this longer-term after people are vaccinated to see how long immunity will last.”

Booster shots are typically given several years after the first, though children will often receive them earlier to provide a more “robust immune response,” said Chagla. “For most adult vaccinations you have a series [of doses], and things like the pneumonia shot or tetanus shot you do at five, 10-year intervals after getting it just knowing that immunity wanes in some of the older populations,” he said.

As with any vaccine that requires multiple doses, the first dose exposes the body to the COVID-19 virus to kickstart an immune response. The second dose “gets the engine running quicker,” infectious disease specialist Anna Banerji told CTVNews.ca. “The second time the body sees the virus it responds quicker because the antibodies are there and you can have a much more immediate response.”

It is still possible to contract COVID-19 after the first or second dose, but data from leading vaccines trials suggest they are effective in preventing infection.

The Pfizer, Moderna and AstraZeneca vaccine candidates all have different requirements for transportation and storage. Pfizer’s vaccine needs to be kept at -70 C during those stages to remain effective, but it is not administered into someone’s veins at that temperature, assured Bogoch.

“God, that would suck. You’d get frostbite. That would cause tremendous damage,” he said. “The Pfizer vaccine is stable for about five days in a conventional refrigerator. The Moderna vaccine needs to be stored at -20 C but it’s stable in a refrigerator for about 30 days.”

The AstraZeneca vaccine candidate can be stored between 2 C and 8 C, which experts consider a major logistical advantage for areas of the country that don’t have access to ultra-cold freezers.

The specifics of the rollout are still being developed or have not yet been announced to Canadians, but experts expect there to be a variety of methods by which people will be vaccinated. Where someone lives may determine which vaccine they receive by which method.

“It’s going to depend on what vaccine is locally available, what resources are in that region to actually administer them,” said Chagla, noting the different storage temperatures required of the Pfizer, Moderna and AstraZeneca candidates.

“I think you’re going to see a lot of different models. You’re going to see family doctor models, drive-thru models, hospital models, models where people are going into long-term care facilities and plastering it among patients and staff,” he said. “You might get other ways of administering it, like mass vaccination clinics.”

Recent lessons from the administration of influenza vaccines may be informing how a COVID-19 vaccine is rolled out, said Chagla, who expects there to be less reliance on lining up at local pharmacies.

“We can’t have people standing in long lineups, particularly in the era of COVID-19,” he said. “People getting COVID waiting for a COVID vaccine seems like fairly poor optics in that sense.”

If someone is vaccinated and they come into contact with the virus, one of two things is going to happen, said Bogoch: “You’re either going to get the infection, or you’re not.”

Early data from COVID-19 vaccine trials suggests that the probability of getting the infection is significantly lower in vaccinated people than in unvaccinated people. Similarly, the early data suggests severe illness is also less common in people who are vaccinated.

“It’s extremely important to note that we don’t have the data available, and we're only going by the snippets of data that we do have available,” he added.

Yes. While a minority of people get sick and die from COVID-19, that small group of people can still overwhelm the hospital system, said Chakrabarti.

“Once that happens, there’s a ripple affect that has effects on everybody’s health,” he said, noting cancer screening appointments are cancelled and elective operations are postponed. As of Dec. 1, some of the largest hospitals in Canada were nearing capacity, threatening widespread cancellations of non-emergency surgeries that would further extend a health care backlog.

While some have suggested protecting the elderly and letting the virus “rip” through society to allow for natural herd immunity, Chakrabarti says it’s very difficult to protect all vulnerable people and the consequences of such a strategy can’t be understated.

“The cost of doing that is that you would overrun hospitals and there would be all sorts of collateral damage,” he said.

Likely yes. Since the Pfizer-BioNTech and Moderna vaccines are not “live-virus” vaccines, there is no concern that a suppressed immune system will get COVID-19 from these shots, said Shapiro. “The concern is that they may not mount as large an immune response, but there is no reason to think that they will not be able to be given the vaccine,” she told CTV News Channel. “Looking at previous histories of this population, we worry about [them] getting sicker with the disease so usually they're a population we like to immunize.”

Maybe, but it’s unlikely that individual people will get each of the Pfizer, Moderna and AstraZeneca vaccines, or some other combination of vaccines, during the first rollout, said Chakrabarti.

“This stuff will be honed in the coming years as we start to get to know more and more. There is a precedent for using vaccines of slightly different mechanisms to give you a synergistic type of effect,” he said, noting that high-risk populations are inoculated with both pneumonia vaccines on the market for a more powerful affect.

There’s also added benefit to having multiple vaccines on the market, whether or not an individual person receives multiple shots. The differences in the storage requirements alone provide important benefits, particularly to the developing world, noted Chagla.

“Right now it’s just a race to get a vaccine on the market rather than necessarily saying ‘What’s the optimal strategy?’” he said. “As things go on, we’re probably going to get more and more data to say which one is better in kids, which one is better in the elderly, which one is better in certain settings, or with certain medications. That’s the benefit fo having multiple on the market.”

While some experts expect a feeling of “normal” to return at some point next year, a complete return to normal might not come until 2022.

“The rollout of the vaccine is a gargantuan task,” said Chakrabarti. “I do completely expect that things will be back to normal sometime in 2022. I think 2021 will be a gradual and stepwise improvement in our daily lives and the case count.”

Chagla expects people will begin to “step off the brake” once the most vulnerable populations are vaccinated in the early months of 2021. Summer could be close to normal, he added. “We’re going to see ‘normal’ starting to show up more and more and more as some of those higher-risk settings get more and more vaccinated,” he said.

Yes. Until more of the population has been vaccinated, it’s likely that mask mandates will remain in place across much of Canada. While the COVID-19 vaccines being distributed have proven to be very effective at preventing infection, it’s still possible that inoculated individuals could be asymptomatic and unknowingly spread the disease. “There’s nothing there [in Pfizer’s data] that suggests that people are less transmissible,” Chagla told CTVNews.ca in December. “All we know is individuals who got the vaccine had less symptomatic disease than people who didn’t get the vaccine.”

The approach to distributing the Pfizer and Moderna vaccines, which both require two doses, varies from province to province. In Ontario, for example, officials have opted to reserve enough doses in order to fully vaccinate people who have already received their first dose. Conversely, in some other provinces, including Quebec, officials decided to use all available vaccine supplies to provide more people with their first dose. Expert opinion on what is the appropriate approach varies.

The COVID-19 vaccines currently in rotation have not been tested in children and most teens. Last month, Pfizer-BioNTech released more data from its clinical trials in which there were no people younger than 16 among all 43,448 participants. "They can't really say this vaccine is recommended for an age group that hasn't been tested yet," Dr. Anna Banerji, an infectious diseases pediatrician and associate professor of pediatrics at the University of Toronto, told CTVNews.ca in a phone interview last month.