Archived 9: Recommendations on the use of COVID-19 vaccines [2021-05-03]

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This is an archived version. Please refer to the most current version of this statement.
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Organization: Public Health Agency of Canada

Published: 2021-05-03

Important notice

On May 5, 2021, Health Canada authorized the Pfizer-BioNTech COVID-19 vaccine for use in children 12 to 15 years of age. NACI will be issuing updated guidance in the coming weeks. Until then, the term 'authorized age group' refers to individuals 16 years of age and over for the Pfizer-BioNTech COVID-19 vaccine.

Publication date: May 3, 2021

On this page

Table of updates

This evergreen document will be updated as COVID-19 vaccines are authorized and become available for use in Canada, and as evidence on these vaccines and COVID-19 evolves. This table summarizes the latest changes to this current version. Please refer to the Table of updates for a full list of updates to previous versions.
Section Update Date
Vaccines

All sub-sections under the section “Vaccines” have been updated to include evidence or information from the product monograph related to the Janssen COVID-19 vaccine. This includes:

  • Table 1. COVID-19 vaccines authorized for use in Canada
  • Efficacy and Effectiveness
  • Immunogenicity
  • Vaccine administration
  • Storage requirements
  • Vaccine safety and adverse events following immunization
2021-05-03
Vaccines A section on immunogenicity in individuals previously infected with SARS-CoV-2 has been included. 2021-05-03
Vaccines A section on adverse events following the second dose of COVID-19 vaccine in individuals previously infected with SARS-CoV-2 has been included. 2021-05-03
Recommendations NACI's overarching recommendation on the use of COVID-19 vaccines has been updated to include guidance on the use of the Janssen COVID-19 vaccine. The summary of evidence and rationale for this recommendation has been updated. 2021-05-03
Recommendations

NACI's preferential recommendation for the use of mRNA vaccines in pregnancy has been highlighted given the complexities of the clinical management of Vaccine Induced Immune Thrombotic Thrombocytopenia (VITT) in pregnancy should it occur after vaccination with a viral vector vaccine. In addition, preliminary data is now available on mRNA vaccines administered in pregnancy, with no safety signals detected. The summary of evidence and rationale for the pregnancy and breastfeeding recommendations have been updated with additional information from Developmental and Reproductive Toxicity (DART) animal studies for Janssen COVID-19 vaccine. The evidence summary has also been updated to reflect current research on COVID-19 vaccination during pregnancy and breastfeeding.

2021-05-03
Management options for COVID-19 vaccines authorized and available for use in Canada Table 5 has been updated with data for Janssen COVID-19 vaccine. 2021-05-03
Appendix D Evidence on the efficacy, immunogenicity and safety of the Janssen COVID-19 vaccine has been added in a new appendix. 2021-05-03
Appendix E Tables capturing the frequency of solicited adverse events following immunization in clinical trials with mRNA and viral vector COVID-19 vaccines have been updated. 2021-05-03
Appendix F The benefit risk assessment for the use of Janssen COVID-19 vaccine in a public health context has been added. 2021-05-03
Appendix G Information on pregnancy and COVID-19 vaccine registries has been added in a new appendix. 2021-05-03

Preamble

The National Advisory Committee on Immunization (NACI) is an External Advisory Body that provides the Public Health Agency of Canada (PHAC) with independent, ongoing and timely medical, scientific, and public health advice in response to questions from PHAC relating to immunization.

In addition to burden of disease and vaccine characteristics, PHAC has expanded the mandate of NACI to include the systematic consideration of programmatic factors in developing evidence-based recommendations to facilitate timely decision-making for publicly funded vaccine programs at provincial and territorial levels.

The additional factors to be systematically considered by NACI include: economics, ethics, equity, feasibility, and acceptability. Not all NACI Statements will require in-depth analyses of all programmatic factors. While systematic consideration of programmatic factors will be conducted using evidence-informed tools to identify distinct issues that could impact decision-making for recommendation development, only distinct issues identified as being specific to the vaccine or vaccine-preventable disease will be included.

This statement contains NACI's independent advice and recommendations, which are based upon the best current available scientific knowledge.

This document is being disseminated for information purposes. People administering the vaccine should also be aware of the contents of the relevant product monograph(s). Recommendations for use and other information set out herein may differ from that set out in the product monograph(s) of the Canadian manufacturer(s) of the vaccines. Manufacturer(s) have sought approval of the vaccines and provided evidence as to its safety and efficacy only when it is used in accordance with the product monographs. NACI members and liaison members conduct themselves within the context of PHAC's Policy on Conflict of Interest, including yearly declaration of potential conflict of interest.

Summary

The following highlights key, current information for immunization providers on COVID-19 vaccine. The evidence on COVID-19 disease and vaccines is evolving. Evidence from clinical trial data is limited due to limitations in the size and duration of follow-up of trial populations. However, clinical trials and studies in the real-world setting are ongoing. NACI will continue to monitor the evidence and update its recommendations as needed. Please refer to the remainder of the Statement for details.

What

Disease

Currently authorized and available vaccines (Pfizer BioNTech COVID-19 vaccine, Moderna COVID-19 vaccine, AstraZeneca COVID-19 vaccine, Janssen COVID-19 vaccine)

Who

NACI makes the following recommendations:

A complete series with an mRNA COVID-19 vaccine should be preferentially offered to individuals in the authorized age group without contraindications to the vaccine. If an mRNA vaccine is contraindicated, another authorized COVID-19 vaccine should be offered.

A complete series with a viral vector COVID-19 vaccine may be offered to individuals 30 years of age and older without contraindications only if the individual prefers an earlier vaccine rather than to wait for an mRNA vaccine and all the following conditions apply:

  1. The benefit-risk analysis* determines that the benefit of earlier vaccination with a viral vector COVID-19 vaccine outweighs the risk of COVID-19 while waiting for an mRNA COVID-19 vaccine; and
  2. The benefits and relative risk* and consequences of VITT and COVID-19 for the individual are clearly outlined, factoring in the anticipated waiting time to receive an mRNA vaccine as well as the availability of other effective personal public health measures to mitigate risk of COVID-19, and the individual makes an informed decision based on an understanding about these risks and benefits; and
  3. There will be substantial delay to receive an mRNA vaccine.

Note: Provinces and territories should adapt the age limit, based on their local epidemiology.

*See Risk Assessment Tool and Management Options Table to assist with this determination

A complete vaccine series with a currently authorized COVID-19 vaccine may be offered to:

For some specific populations who were either excluded from, or were represented by small numbers of participants in clinical trials, NACI recommends that a complete vaccine series with a currently authorized COVID-19 vaccine may be offered, if a risk assessment deems that the benefits of vaccination outweigh the potential risks for the individual (e.g., where the risk of severe outcomes of COVID-19 and/or risk of exposure to SARS-CoV-2 is high) or for the fetus/infant (in the case of pregnancy/breastfeeding) and if informed consent includes discussion about the insufficient evidence in these populations:

These recommendations may change as more evidence on safety and/or efficacy/effectiveness in these populations becomes available.

NACI also recommends that:

NACI continues to recommend the following elements to guide ethical decision-making, as outlined in NACI's guidance on Key Populations for Early COVID-19 Immunization:

How

Why

Introduction

The overall goal of Canada's pandemic response is to minimize serious illness and death while minimizing societal disruption as a result of the COVID-19 pandemic. The goal of Canada's COVID-19 immunization response is: To enable as many Canadians as possible to be immunized against COVID-19 as quickly as possible, while ensuring that high risk populations are prioritized.

This guidance document will provide recommendations on the use of authorized COVID-19 vaccines as they are approved and available for use in Canada, and as evidence on these vaccines evolves.

There are four COVID-19 vaccines currently authorized for use in Canada:

  1. The Pfizer-BioNTech COVID-19 vaccine was authorized for use in Canada on December 9, 2020.
  2. The Moderna COVID-19 vaccine was authorized for use in Canada on December 23, 2020.
  3. The AstraZeneca COVID-19 vaccine was authorized for use in Canada on February 26, 2021.
    • Health Canada authorized two manufacturers to produce this vaccine developed by AstraZeneca and Oxford University: AstraZeneca and Serum Institute of India (SII). NACI has not specifically reviewed evidence for the SII vaccine, but Health Canada has deemed SII and AstraZeneca vaccines to be comparable. Authorization of the SII COVID-19 vaccine (COVISHIELD) was based on its comparability to the AstraZeneca COVID-19 vaccine as determined by evaluation and direct comparison of manufacturing processes and controls and the quality characteristics of the two products. The results of this comparison by Health Canada determined that the two products were sufficiently similar and that the efficacy, immunogenicity and safety of COVISHIELD could be inferred from the non-clinical and clinical studies from the AstraZeneca COVID-19 vaccine.
  4. The Janssen COVID-19 vaccine was authorized for use in Canada on March 5, 2021.

The evidence on COVID-19 and COVID-19 vaccines has been rapidly evolving. To date, NACI has published the following evidence-informed guidance:

  1. Research priorities for COVID-19 vaccines to support public health decisions to inform clinical trials of candidate COVID-19 vaccines to protect against infection, serious illness, and deaths caused by SARS-CoV-2.
  2. Preliminary guidance on key populations for early COVID-19 immunization to plan for the efficient, effective, and equitable allocation of an eventual COVID-19 vaccine when limited initial vaccine supply will necessitate the immunization of some populations earlier than others.
  3. Guidance on the prioritization of initial doses of COVID-19 vaccine(s) for the efficient and equitable prioritization of initial doses of COVID-19 vaccines to assist with the planning for allocation of the first COVID-19 immunization programs.
  4. Guidance on the prioritization of key populations for COVID-19 immunization to provide guidance for the equitable, ethical, and efficient allocation of authorized COVID-19 vaccines in the context of staggered arrival of vaccine supply that will necessitate offering vaccines to some populations earlier than others.
  5. Rapid response: Extended dose intervals for COVID-19 vaccines to optimize early vaccine rollout and population protection in Canada to maximize the number of individuals benefiting from the first dose of vaccine by extending the interval for the second dose up to four months after the first. This was followed by a more comprehensive NACI statement providing a detailed overview of the evidence and considerations leading to NACI's recommendation.
  6. Rapid response: Recommended use of AstraZeneca COVID-19 vaccine in younger adults (AstraZeneca vaccine should not be used in adults under 55 years of age at this time) while the safety signal of Vaccine-Induced Prothrombotic Immune Thrombocytopenia (VIPIT) [now and hereafter referred to as Vaccine-Induced Immune Thrombotic Thrombocytopenia ( VITT)] following vaccination with AstraZeneca COVID-19 vaccine is investigated further.
  7. Recommendations on the use of COVID-19 vaccine initially published on December 12, 2020 and updated iteratively as new evidence becomes available and the authorization of additional COVID-19 vaccines. This statement reflects the most up to date guidance.

Guidance objective

The objective of this advisory committee statement is to provide evidence-informed guidance on the effective and equitable use of COVID-19 vaccines authorized and available for use in Canada. This evergreen document will be updated as COVID-19 vaccines are authorized and become available for use in Canada, and as the evolution of evidence on these vaccines or the pandemic situation warrants changes in guidance. In this guidance document, the evidence and rationale for recommendations as well as current knowledge gaps will be summarized. Evidence summaries on vaccine characteristics for specific COVID-19 vaccines will be included in appendices.

Methods

Details of NACI's recommendation development process can be found elsewhere.Footnote 1 Footnote 2

In brief, the broad stages in the preparation of this NACI advisory committee statement included:

In order to develop comprehensive, appropriate immunization program recommendations, NACI considers a number of factors. In addition to critically appraising evidence on burden of disease and vaccine characteristics such as safety, efficacy, immunogenicity and effectiveness, NACI uses a published, peer-reviewed framework and evidence-informed tools to ensure that issues related to ethics, equity, feasibility, and acceptability (EEFA) are systematically assessed and integrated into its guidanceFootnote 2. The NACI Secretariat applied this framework with accompanying evidence-informed tools (Ethics Integrated Filters, Equity Matrix, Feasibility Matrix, Acceptability Matrix) to systematically consider these programmatic factors for the development of clear, comprehensive, appropriate recommendations for timely, transparent decision-making. For details on the development and application of NACI's EEFA Framework and evidence-informed tools (including the Ethics Integrated Filters, Equity Matrix, Feasibility Matrix, and Acceptability Matrix), please see A framework for the systematic consideration of ethics, equity, feasibility, and acceptability in vaccine program recommendations.

For this advisory committee statement, NACI used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework to develop population-focused recommendations. Further information on this framework can be found in the GRADE handbook.

NACI reviewed and approved the key policy questions used to guide recommendation development on November 25, 2020 and rated the outcomes for their importance for decision-making. The Canadian Immunization Committee (CIC) provided feedback on the key policy questions to ensure alignment with program needs. Important ethical considerations relating to the key policy questions were presented on November 26, 2020, December 15, 2020, January 26, 2021, and April 6, 2021 to the PHAC Public Health Ethics Consultative Group, who provided an assessment of ethical considerations that are relevant to the development of recommendations. Knowledge synthesis and quality appraisal were performed by the NACI Secretariat for unpublished clinical trial evidence and were informed by NACI's rating of the outcomes. Unpublished data from Phase 1, 2, and 3 clinical trials were presented to the High Consequence Infectious Disease Working Group and NACI for discussion. Proposed recommendations were then presented and approved at emergency NACI meetings. The description of relevant considerations, rationale for specific decisions, and knowledge gaps are described in the text.

Key Dates:

Epidemiology

Information on COVID-19 is continually evolving. The following section will describe the current basis of knowledge, with an emphasis on the best available Canadian data where possible. To access the most recent updates to specific elements, please refer to the links below.

Disease description

Infectious agent

COVID-19 is caused by the SARS-CoV-2, which was first recognized in Wuhan, China in December 2019.

Transmission

Current evidence suggests that COVID-19 is spread through respiratory droplets and aerosols created when an infected person coughs, sneezes, sings, shouts, or talks. A person may be infectious for up to three days before showing symptoms.

More information on the transmission of COVID-19 can be found on the PHAC webpages for COVID-19: Main modes of transmission and COVID-19 signs, symptoms and severity of disease: A clinician guide.

Variants of concern

Genetic mutations in the SARS-CoV-2 virus have been identified, some of which make the virus more infectious and transmissible. They may also affect the severity of disease and the level of protection offered by vaccines against them.

More information on the variants of concern (VOC) reported in Canada is available in the COVID-19 epidemiology update. The COVID-19 Weekly Epidemiological Update by the World Health Organization provides a summary on the global distribution and emerging evidence on VOC and variants of interest.

NACI will continue to monitor the epidemiology and evidence pertaining to VOC and COVID-19 vaccines.

Risk factors

Anyone can be infected with SARS-CoV-2. However, some populations are at increased risk of exposure to the virus (e.g., due to living or occupational settings), and some populations are at increased risk of severe disease and outcomes (e.g., hospitalization and death) due to various biological (e.g. advanced age, pre-existing medical conditions) and social (e.g., socioeconomic status, belonging to a racialized population) factors that may intersect. Exposure and risk of severe disease factors may overlap, further increasing risk. Any combination of these factors, as well as varying access to health care services, has the potential for disproportionate consequences for specific populations characterized by increased rates of infection and disease, severe illness, hospitalizations, and/or deaths.

Please see NACI's Advisory Committee Statement on Key Populations for Early COVID-19 Immunization and the Equity MatrixFootnote 3 for a summary of inequities associated with COVID-19, potential reasons for and intersections between these inequities, and suggested interventions to reduce inequities and improve access to vaccines NACI's Guidance on the prioritization of key populations for COVID-19 immunization builds on the foundational framework for the equitable, ethical and efficient allocation of authorized COVID-19 vaccines in the context of staggered arrival of vaccine supply that will necessitate offering vaccines to some populations earlier than others. This guidance was informed by evolving evidence on risk factors for COVID-19.

Table 1 summarizes populations at risk of severe outcomes from COVID-19 (hospitalization and/or mortality) based on the results of an updated rapid review of evidenceFootnote 4 from studies in Organisation for Economic Co-operation and Development (OECD) countries, as well as populations at increased risk of exposure to COVID-19 (due to inability to physically distance and/or reduced access to infection prevention and control measures) identified, in part, through Canadian reports (epidemiological or analytic).

The review by the Alberta Research Centre for Health Evidence (ARCHE) found strong evidence (of moderate or high certainty) for at least a 2-fold increase in mortality from COVID-19 with age 60-69 years versus <60 years. A previous review by ARCHE found a moderate certainty of evidence for at least a 5-fold increase in mortality and hospitalization with age over 70 years (versus 45 years and younger). Studies treating age on a continuum or across small increments consistently found that risks for hospitalization and mortality increased with increasing age (e.g., approximately 2-6% and 5-10% relative increase in risk per year)Footnote 5.

The ARCHE review found strong evidence (of moderate or high certainty) for at least a 2-fold increase in mortality from COVID-19 with a small number of medical conditions (classified as Level 1 in Table 1). The review found a low certainty of evidence for at least a 2-fold increase in mortality from COVID-19, and/or a low or moderate certainty of evidence for at least a 2-fold increase in hospitalization for a longer list of medical conditions (classified as Level 2 in Table 1). A moderate certainty of evidence of at least a 2-fold increase in hospitalization and mortality from COVID-19 in people living with two or more medical conditions was found. However, there is no direct evidence on the combination of medical conditions that increase this riskFootnote 5.

Caution should be taken when interpreting evidence of low certainty (e.g., for medical conditions listed as Level 2 in Table 1). As evidence accumulates, observed associations may change. For example, a previous rapid review by ARCHEFootnote 5 found low certainty evidence for at least a 2-fold increase in hospitalization or mortality for males, people with liver disease, and people with heart failure. As evidence has accumulated, there is now stronger evidence for little-to-no increased association of severe outcomes in these populations. The list of medical conditions included in Table 1 may not be comprehensive as it is based only on evidence from published studies included in the ARCHE review.

Table 1. Summary of risk factors for severe outcomes from COVID-19 and increased risk of exposure to COVID-19
Increased risk of severe outcomes from COVID-19 (hospitalization/mortality)Footnote a Increased risk of exposure to COVID-19Footnote 4
(e.g., due to inability to physically distance/reduced access to IPC)Footnote b

Increasing age (strong evidence)

(based on moderate certainty of evidence of ≥2-fold increase in mortality)

  • ≥60 years (particularly ≥ 70 years)Footnote 4
  • Residents and staff of congregate living settings that provide care for seniors
  • Frontline healthcare workers
  • Adults in Indigenous communities
  • Residents and staff of other congregate living settings (e.g., quarters for migrant workers, shelters, correctional facilities, group homes)
  • Adults in racialized and marginalized communities
  • First responders (e.g., police, firefighters)
  • Frontline essential workers who cannot work virtually

Medical conditions - Level 1 (strong evidence)Footnote 5

(based on moderate or high certainty evidence of ≥2-fold increase in mortality)

  • Down syndrome
  • End-stage kidney disease
  • Epilepsy
  • Motor neuron disease, multiple sclerosis, myasthenia gravis, Huntington's diseaseFootnote §
  • Type 1 and 2 diabetes

Medical conditions - Level 2 (limited evidence)Footnote 5

Level 2a (based on low certainty of evidence of ≥2-fold increase in mortality

  • Cerebral palsy
  • Major psychiatric disorder (schizophrenia, schizoaffective disorder, or bipolar disorder); in combination with drug use for the condition in the past 6 months
  • Obesity class III (BMI 40 kg/m2 or more)
  • Parkinson's disease
  • Sickle cell disease or severe immunodeficiency, transplant (any type)
  • Kidney transplant,
  • Recent bone marrow or stem cell transplant
  • Metastatic cancer
  • Recent/current chemotherapy or radiotherapy

Level 2b (based on low or moderate certainty of evidence of ≥2-fold increase in hospitalization)

  • Previous cerebrovascular accident
  • Pregnancy (any stage)
  • Frailty (among community and non-community dwelling people; measured on scales that include items such as weight loss, exhaustion, physical activity, walking speed, grip strength, overall health, disability, presence of disease, dementia, falls, mental wellbeing)

Increased risk of severe outcomes (hospitalization/mortality)Footnote c and Increased risk of exposureFootnote 5

  • Long-term care residents
  • Visible minority groups (includes mainly South Asian, Chinese, Black, Filipino, Latin American, Arab, Southeast Asian, West Asian, Korean, Japanese)

Footnotes

Footnote a

Identified through rapid review of evidence from OECD countries for an independent association with severe outcomes from COVID

Return to footnote a referrer

Footnote b

Identified, in part, through Canadian epidemiological reports

Return to footnote b referrer

Footnote c

Identified through rapid review of Canadian studies that may have an association with hospitalization and mortality from COVID-19. These studies may not have accounted for other covariates.

Return to footnote c referrer

Footnote §

These conditions were grouped within a single study; evidence for the individual conditions is either unavailable or of lower certainty.

Return to footnote § referrer

The list of medical conditions in Table 1 may differ from those in other jurisdictions due to differences in local epidemiology and differing levels of evidence considered.

The evidence on risk factors for COVID-19 continues to evolve.

Spectrum of clinical illness

The median incubation period for non-variant SARS-CoV-2 has been estimated to be 5 to 6 days from exposure to symptom onset, with most individuals (97.5%) developing symptoms within 11.5 days of exposure. The incubation period ranges from 1 to 14 days.

Clinical presentation and symptoms of COVID-19 vary in frequency and severity. To date, there is no list of symptoms that has been validated to have high specificity or sensitivity for COVID-19.

More information on the spectrum of clinical illness is available on the PHAC webpage for COVID-19 signs, symptoms and severity of disease: A clinician guide.

Disease incidence

Global

Updated international data on COVID-19 cases and deaths is available at: Interactive data visualizations of COVID-19.

Weekly epidemiological updates highlighting key global, regional and country-level data on COVID-19 cases and deaths are available from the World Health Organization (WHO) at: Coronavirus disease (COVID-19) Weekly Epidemiological Update and Weekly Operational Update.

National

Updated national, provincial and territorial-level data on COVID-19 cases and deaths in Canada over time is available from the PHAC webpage on Coronavirus disease (COVID-19): Outbreak update.

Vaccines

The following section summarizes information about COVID-19 vaccines authorized for use in Canada. More detailed vaccine-specific information is included in Appendices A through D. The current landscape of all candidate COVID-19 vaccines in clinical evaluation can be found on the WHO webpage Draft landscape of COVID-19 candidate vaccines. Under the Interim Order Respecting the Importation, Sale and Advertising of Drugs for Use in Relation to COVID-19, Health Canada can make regulatory decisions for COVID-19 vaccines that have completed Phase 3 clinical trials for authorized use in Canada.

Most vaccine candidates in development that may become authorized for use in Canada use various technologies to deliver SARS-CoV-2 spike protein to vaccine recipients. This protein is expressed on the surface of the SARS-CoV-2 virus and is a major target for binding and neutralizing antibodies as well as cell-mediated immune responses.

mRNA vaccines

COVID-19 vaccines that use messenger RNA (mRNA) platforms contain modified nucleotides that code for the SARS-CoV-2 spike protein. A lipid nanoparticle formulation delivers the mRNA into the recipient's cells. Once inside the cytoplasm of a cell, the mRNA provides instructions to the cell's protein production machinery to produce the trans-membrane spike protein antigen that becomes anchored on the cell's external surface. The mRNA does not enter the nucleus of the cell and does not interact with, or alter, human DNA. The immune system is engaged by both the transmembrane spike protein and immune receptors carrying spike antigens to induce humoral and cellular immune responses. The mRNA, lipid nanoparticle, and spike protein are degraded or excreted within days to weeks from time of immunization. mRNA vaccines are not live vaccines and cannot cause infection in the host.

Canada has procured and is expecting enough mRNA vaccines to fully vaccinate the currently eligible Canadian population before fall 2021.

Non-replicating viral vector vaccines

COVID-19 vaccines based on viral vector platforms use a modified virus to carry genes that encode SARS-CoV-2 spike proteins into the host cells. The vector virus is a type of adenovirus that has been modified to carry COVID-19 genes and to prevent replication. These modifications are intended to prevent the viral vector from causing disease. (i.e., they are non-replicating). Once inside the cell, the SARS-CoV-2 spike protein genes are transcribed into mRNA in the nucleus and translated into proteins in the cytosol of the cell. The AstraZeneca vaccine uses a modified chimpanzee adenovirus vector (ChAd). The Janssen vaccine uses a modified human adenovirus serotype 26 vector (Ad26).

Preparations of COVID-19 vaccines authorized and available for use in Canada

Table 2 : COVID-19 vaccines available for use in Canada
Product Brand Name Pfizer-BioNTech COVID-19 Vaccine Moderna COVID-19 Vaccine AstraZeneca COVID-19 / Covishield Vaccine Janssen COVID-19 Vaccine
Type of vaccine mRNA mRNA Non-replicating viral vector (ChAd) Non-replicating viral vector (Ad26)
Date of authorization in Canada December 9, 2020 December 23, 2020 February 26, 2021 March 5, 2021
Authorized ages for use 16 years of age and older 18 years of age and older 18 years of age and older 18 years of age and older
Dose 0.3 mL (30 mcg of mRNA)Footnote a 0.5 mL (100 mcg of mRNA) 0.5 mL (5 x 1010 viral particles) 0.5 mL (5 x 1010 viral particles)
Authorized ScheduleFootnote b 2 Doses, 3 weeks apart 2 Doses, 4 weeks apart 2 Doses, 4 to 12 weeks apart 1 Dose
Route of administration IM IM IM IM
Nature of the antigen Transmembrane prefusion spike protein Transmembrane prefusion spike protein Transmembrane spike protein Transmembrane prefusion spike protein
Adjuvant (if present) None None None None
Primary storage requirements pre-puncture -80°C to -60°C -25°C to -15°C c +2ºC to +8ºC +2ºC to +8ºC
Additional storage options pre-punctureFootnote c -25°C to -15°C for up to 2 weeksFootnote e
or
120 hours (5 days) at +2°C to +8°C
and/or

2 hours up to +25°C
30 days at +2°C to +8°C
and/or

12 hours at +8°C to +25°C
+2ºC to +8ºC +2ºC to +8ºC
Diluent Yes No No No
Usage limit post-puncture 6 hours at +2°C to +25°CFootnote f 6 hours at +2°C to +25°C 6 hours at room temperature (up to +30ºC)
or
48 hours at +2ºC to +8ºC
3 hours at room temperature (up to +25ºC)
or
6 hours at +2ºC to +8ºC
Formats available Multi-dose vial (6 doses)Footnote a, preservative-free Multi-dose vial (10 doses), preservative-free Multi-dose vial (8-and 10-dose presentations), preservative-free Multi-dose vial (5 doses), preservative-free

Footnotes

Footnote a

After dilution, one vial contains 6 doses of 0.3 mL each. However, vial labels and cartons may state that after dilution, a vial contains 5 doses of 0.3 mL. Information in the product monograph supersedes the number of doses stated on vial labels and cartons. Low dead-volume syringes and/or needles can be used to extract 6 doses from a single vial. If standard syringes and needles are used, there may not be sufficient volume to extract a 6th dose from a single vial. Refer to the product monograph available through Health Canada's Drug Product Database for choice of diluent, dilution instructions and type of syringes which can be used to extract 6 doses from a single vial.

Return to footnote a referrer

Footnote b

Authorized schedule per the product monograph. For NACI recommendations on intervals between doses refer to Table 3 for details

Return to footnote b referrer

Footnote c

Protected from light during storage

Return to footnote c referrer

Footnote d

Do not store on dry ice or below -40ºC

Return to footnote d referrer

Footnote e

Vials stored at -25°C to -15°C for up to 2 weeks may be returned one time to the recommended storage condition of -80°C to -60°C. Total cumulative time the vials are stored at -25°C to -15°C should be tracked and should not exceed 2 weeks.

Return to footnote e referrer

Footnote f

After dilution, vaccine must be used within 6 hours

Return to footnote f referrer

Abbreviations:

  • ChAd: Chimpanzee adenovirus
  • Ad26: modified human adenovirus 26;
  • IM: Intramuscular
  • mRNA: Messenger ribonucleic acid

Efficacy and effectiveness

Due to the availability of only short-term clinical trial data, the duration of protection provided by COVID-19 vaccination is currently unknown. However, studies are ongoing.

The following section highlights key efficacy and effectiveness data for authorized COVID-19 vaccines (Pfizer-BioNTech COVID-19 vaccine, Moderna COVID-19 vaccine) and the authorized, viral vector based COVID-19 vaccine (AstraZeneca COVID-19 vaccine, Janssen COVID-19 vaccine) only. For additional details regarding trial design, including study population, length of follow-up, and efficacy for the authorized and available vaccines, refer to the evidence summary in Appendix A (for the Pfizer-BioNTech COVID-19 vaccine), Appendix B (for the Moderna COVID-19 vaccine), Appendix C (for the AstraZeneca COVID-19 vaccine) and Appendix D (for the Janssen COVID-19 vaccine).

Efficacy against symptomatic COVID-19 disease

The currently authorized mRNA COVID-19 vaccines have been shown to be highly efficacious in the short term against confirmed symptomatic COVID-19 disease (presence of one or more symptoms plus laboratory confirmation of SARS-CoV-2 infection) from one to two weeks after receiving the full two-dose series. The authorized mRNA vaccines are similarly efficacious in adults with one or more comorbidities, as well as in younger adults and older adults. However, evidence in adults of a much more advanced age (e.g., 85 years and older) and in long-term care facilities is limited. In clinical trials, AstraZeneca COVID-19 viral vector vaccine has shown moderate short-term efficacy against symptomatic COVID-19 disease (presence of at least one pre-defined COVID-19 symptom plus laboratory confirmation of SARS-CoV-2 infection) in adults 18-64 years of age, at least two weeks after receiving the full series of two standard doses of the vaccine. Clinical trial data show that efficacy increased as the interval between doses increased. At present, there are insufficient clinical trial data in adults ≥65 years of age to assess vaccine is efficacy in this age group. The vaccine is similarly efficacious in adults ≥18 years of age with and without pre-defined comorbidities (presence of one or more mild to moderate and controlled cardiovascular disease, respiratory disease, diabetes or obesity).

In the initial absence of sufficient data from clinical trials to date on the efficacy of the AstraZeneca COVID-19 vaccine in those 65 years of age and older, a review of three observational studies in the UK published as pre-prints on vaccine effectiveness in this age group has been conducted to inform NACI's recommendations in this age group. The findings of this review are summarized in Appendix C. These studies provide effectiveness estimates following the first dose of AstraZeneca vaccine and have shown a reduction in the risk of symptomatic disease and hospitalization that appears to reach a comparable level to that observed among persons of similar age who received one dose of mRNA vaccine.

The Janssen COVID-19 vaccine demonstrates moderate efficacy against symptomatic confirmed moderate to severe/critical COVID-19 infection from 14 days and 28 days post-vaccination, where the definition of moderate disease includes the presence of one to two or more of a relatively broad range of COVID-19 compatible signs and symptoms plus laboratory confirmation of SARS-CoV-2 infection. The point estimates of vaccine efficacy at these two time points across a variety of age groups are similar to the overall estimate, including among study participants ≥65 years of age who comprised approximately 20% of the study population. Point estimates of vaccine efficacy at 14 days post-vaccination are comparable in study participants with and without one or more comorbidities. In contrast, the point estimate of efficacy in participants with comorbidities is somewhat lower at 28 days post-vaccination.

The clinical trial data demonstrates that the authorized mRNA COVID-19 vaccines are efficacious over the short-term in individuals with or without evidence of prior SARS-CoV-2 infection. However, participants with laboratory-confirmed (using a nucleic acid amplification test, such as RT-PCR) SARS-CoV-2 infection prior to enrollment were excluded from the trials and the number of trial participants with evidence of previous infection (as defined by trial protocol) who had confirmed symptomatic COVID-19 disease during the trials were small; therefore, the efficacy in this population and how it compares to those without evidence of previous infection is unknown at this time. The efficacy of the Janssen COVID-19 vaccine in those with evidence of prior infection is inconclusive at this time due to small sample size, and this outcome has not been assessed for AstraZeneca COVID-19 vaccine.

The first dose of the authorized COVID-19 vaccines has been shown to offer at least short-term protection against confirmed COVID-19 disease. For mRNA vaccines, the highest efficacy is seen after the second dose is administered. There is currently no available evidence on medium- and long-term efficacy of the authorized COVID-19 vaccines, however trials are ongoing and this Statement will be updated as evidence emerges.

Efficacy and effectiveness against severe disease

The clinical trials of the authorized and available COVID-19 vaccines assessed efficacy against severe COVID-19 disease, but not all provided sufficient data to be able to assess the efficacy against severe COVID-19 disease, but not all provide sufficient data to be able to assess the efficacy against hospitalizations or deaths.

The authorized mRNA COVID-19 and the Janssen vaccines appear efficacious against severe COVID-19 outcomes based on clinical trial data used for authorization (severe outcomes were defined as laboratory-confirmed COVID-19 with one of the following additional features: clinical signs at rest that are indicative of severe systemic illness; respiratory failure; evidence of shock; significant acute renal, hepatic, or neurologic dysfunction; admission to an intensive care unit; or death). However, the number of severe cases that have been observed to date was small in the Pfizer-BioNTech clinical trial and was too small in the AstraZeneca clinic trial to assess efficacy. Efficacy against hospitalization was not assessed in the clinical trials of the mRNA vaccines, but evidence from the clinical trials involving the viral vector vaccines is suggestive of a protective effect against hospitalization. To date there have been very few COVID-19 associated deaths identified in the clinical trials making it difficult to assess efficacy against this outcome. However, of the COVID-19 associated deaths identified in clinical trials, none have been in study participants receiving COVID-19 vaccines.

Emerging real world evidence from studies in the United Kingdom (UK)Footnote 6 Footnote 7 Footnote 8, IsraelFootnote 9 Footnote 10 Footnote 11 Footnote 12, the United States (US)Footnote 13, and CanadaFootnote 14 suggests moderate to high vaccine effectiveness against severe COVID-19 outcomes after the first or second dose of mRNA COVID-19 vaccinesFootnote 6 Footnote 7 Footnote 8 Footnote 9 Footnote 10 Footnote 11 Footnote 12 Footnote 13 Footnote 14, and after the first dose of AstraZeneca COVID-19 vaccineFootnote 6 Footnote 7 Footnote 8, including in olderFootnote 6 Footnote 7 Footnote 8 Footnote 11 and frailFootnote 6 populations. COVID-19 related hospitalization was the most common severe COVID-19 outcome assessedFootnote 6 Footnote 7 Footnote 8 Footnote 9 Footnote 12 Footnote 13, while fewer studies provided estimates of effectiveness against severe diseaseFootnote 9 Footnote 10 and deathFootnote 7 Footnote 9 Footnote 14. Emerging evidence from Israeli studies suggest high vaccine effectiveness after the second dose of Pfizer-BioNTech COVID-19 vaccine against severe diseaseFootnote 9 Footnote 10, COVID-19 related hospitalizationFootnote 9 Footnote 12 and deathFootnote 12. Studies for COVID-19 vaccines are ongoing and new effectiveness data against severe COVID-19 outcomes will be assessed as it emerges.

Efficacy and effectiveness against asymptomatic infection and transmission

Preliminary data from the ongoing Moderna COVID-19 vaccine trial showed a lower prevalence of SARS-CoV-2 positivity by PCR in asymptomatic participants at one particular time point (before Dose 2), and therefore viral shedding, in the group that received the vaccine compared to the placebo group. However, the current data is insufficient to draw conclusions. Exploratory analyses for the viral vector vaccine have not demonstrated efficacy against confirmed SARS-CoV-2 asymptomatic infection, however the number of asymptomatic infections was small. The clinical trial of the Janssen COVID-19 vaccine found the vaccine to have moderate protection against asymptomatic and undetected COVID-19 infection. Studies are ongoing for these vaccines.

Evidence has begun to emerge from post-marketing studies conducted in IsraelFootnote 9, the UKFootnote 15, and the USFootnote 16 on the effectiveness of COVID-19 vaccines against asymptomatic infection. Estimates of vaccine effectiveness for the Pfizer-BioNTech COVID-19 vaccine against SARS-CoV-2 infection with no reported symptoms was moderate to high after the first doseFootnote 9 Footnote 15(depending on time since vaccination) and high after the second doseFootnote 9 Footnote 15. Similar results were reported for mRNA COVID-19 vaccines in general (i.e., Moderna and Pfizer-BioNTech)Footnote 16. In one UK study, asymptomatic SARS-CoV-2 infections were significantly less likely to be identified in vaccinated participants compared to those who were unvaccinatedFootnote 15. There are no results specific to other COVID-19 vaccines yet, but studies are ongoing.

Efficacy and effectiveness against variants

Evidence of varying protection and effectiveness offered by authorized mRNA COVID-19 vaccines (Pfizer-BioNTech COVID-19 vaccine, Moderna COVID-19 vaccine) and the viral vector-based COVID-19 vaccines (AstraZeneca COVID-19 vaccine, Janssen COVID-19 vaccine) against variants of SARS-CoV-2 is evolving. Please see Table 5 for a summary of this evidence.

The Janssen clinical trial was conducted during the time of emergence of SARS-CoV-2 VOC. As part of the testing conducted during the trial, a proportion of case isolates were genetically sequenced, and of the sequenced isolates, just over two-thirds of the isolates from Brazil were of the P.2 lineage and nearly all isolates from South Africa were of the B.1.351 lineage. Point estimates of vaccine efficacy against confirmed symptomatic moderate to severe/critical COVID-19 infection with onset from 28 days post-vaccine are comparable to the overall estimate of efficacy against this outcome in Brazil and South Africa.

There is evidence that both the Pfizer and AstraZeneca vaccines protect against the B.1.1.7 SARS-CoV-2 variant first identified in the UK. The AstraZeneca clinical trial was conducted when the B.1.351 lineage was the predominant strain in South Africa, and vaccine efficacy was not demonstrated against this strain.

NACI will continue to monitor the evidence and update recommendations as needed.

Immunogenicity

No immunological correlate of protection has been determined for SARS-COV-2; therefore, all immunological evidence in support of vaccine efficacy is indirect and cannot directly be used to estimate efficacy.

There are several key knowledge gaps that affect the understanding of immune responses to COVID-19 vaccine:

Due to limitations in the number of participants and duration of follow up from COVID-19 clinical trial data, long-term evidence on immunogenicity is unknown. However, studies are ongoing.

The following section highlights key immunogenicity data for the authorized mRNA COVID-19 vaccines (Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine) and viral vector based COVID-19 vaccines (AstraZeneca COVID-19 vaccine) only. For additional details regarding trial design, including study population and length of follow-up, and immunogenicity for these authorized vaccines refer to the evidence summaries in Appendix A (for the Pfizer-BioNTech COVID-19 vaccine), Appendix B (for the Moderna COVID-19 vaccine), Appendix C (for the AstraZeneca COVID-19 vaccine) and Appendix D (for the Janssen COVID-19 vaccine).

Humoral immune responses

All authorized COVID-19 vaccines induce humoral immune responses, including binding and neutralizing antibody responses. Humoral responses peaked after the second dose of mRNA vaccine, and after the second dose of AstraZeneca COVID-19 vaccine in participants who were not previously infected. Humoral immune responses were elevated after the one dose of Janssen vaccine. Some vaccines induce higher immune responses in younger populations.

Viral vector-based vaccines may induce anti-vector immune responses, which may impact future vaccine efficacy and effectiveness and may vary by age, dose, and interval between doses.

Cellular immune responses

All authorized, available COVID-19 vaccines have been shown to produce cellular immune responses. Cellular immune responses increased after the second dose of mRNA COVID-19 vaccine, while responses for AstraZeneca COVID-19 vaccine were maintained or decreased after the second dose. Cellular immune responses were present following one dose of Janssen vaccine.

Immunogenicity in individuals previously infected with SARS-CoV-2

Immunogenicity data in previously infected individuals were available from five observational studiesFootnote 17 Footnote 18 Footnote 19 Footnote 20 Footnote 21 Footnote 22 including less than 100 participants. In all studies, individuals with previous SARS-CoV-2 infection had a significantly higher anti-spike and anti-RBD IgG concentrations, neutralizing titres and B and T cell reposes after dose 1 that were comparable to those observed in SARS-CoV-2 naïve individuals following the administration of the second vaccine dose. Elevated binding and neutralizing antibody responses were seen for both symptomatic and asymptomatic previously infected people compared to vaccine recipients who weren't previously infected. These findings were consistent with those reported by the RECOVER Footnote 22 study investigators. However, in the absence of an established correlate of protection, it is not possible to determine the significance of these findings as they relate to the level of protection against reinfection.

Vaccine administration

For additional vaccine product-specific information, consult the product leaflet or information contained within the product monograph available through Health Canada's Drug Product Database. Refer to Vaccine Administration Practices in the Canadian Immunization Guide (CIG), Part 1 - Key Immunization Information for additional general information.

As for the routine administration of all vaccines, COVID-19 vaccines should be administered in settings capable of managing anaphylaxis. Refer to Anaphylaxis and other Acute Reactions Following Vaccination in the CIG, Part 2 - Vaccine Safety for information on the management of anaphylaxis post-vaccination.

Dose, route of administration, and schedule

Dose
Pfizer-BioNTech COVID-19 vaccine

Each dose is 0.3 mL after dilution, containing 30 mcg of SARS-CoV-2 spike protein mRNA.

The dose for the Pfizer-BioNTech COVID-19 vaccine (0.3 mL) is unique compared to that of most routine vaccinations. Special precaution should be taken to ensure the correct dose is taken from the multi-dose vial.

Moderna COVID-19 vaccine

Each dose is 0.5 mL, containing 100 mcg of SARS-CoV-2 spike protein mRNA.

No dilution is required.

AstraZeneca COVID-19 vaccine

Each dose is 0.5 mL, containing 5 x 1010 particles of SARS-CoV-2 spike protein.

No dilution is required.

Janssen COVID-19 Vaccine

Each dose is 0.5 mL, containing 5 x 1010 particles of SARS-CoV-2 spike protein.

No dilution is required.

Route of administration

COVID-19 vaccines are given as an intramuscular (IM) injection into the deltoid muscle. The deltoid muscle of the arm is the preferred injection site in adolescents and adults (unless the muscle mass is not adequate or vaccination in that site is not possible, in which case the anterolateral thigh can be used).

Refer to Vaccine Administration Practices in the CIG, Part 1 - Key Immunization Information for additional information.

Schedule

Refer to Table 3 for a summary of immunization schedules for authorized, available COVID-19 vaccines.

Table 3 : Recommended immunization schedule, by COVID-19 vaccine
Vaccine product (manufacturer) Immunization schedule Minimum interval Authorized interval Extended intervalFootnote a
Pfizer-BioNTech
COVID-19 vaccine
2-dose schedule 19 daysFootnote b 21 days 16 weeks
Moderna
COVID-19 vaccine
2-dose schedule 21 daysFootnote c 28 days 16 weeks
AztraZeneca
COVID-19 vaccine
2-dose schedule 28 days 4 to 12 weeks 16 weeksFootnote d
Janssen
COVID-19 vaccine
1-dose schedule N/A N/A N/A

Footnotes

Footnote a

Based on emerging evidence of the protection provided by the first dose of a two-dose series for COVID-19 vaccines currently authorized and available in Canada, NACI recommends that in the context of limited COVID-19 vaccine supply and ongoing pandemic disease, jurisdictions should maximize the number of individuals benefiting from the first dose of vaccine by extending the second dose of COVID-19 vaccine up to four months after the first. NACI will continue to monitor the evidence and update this interval as needed.

Return to footnote a referrer

Footnote b

The basis for this minimum interval is that the per-protocol design for the Pfizer-BioNTech COVID-19 vaccine clinical trial was 19-23 days

Return to footnote b referrer

Footnote c

The basis for this minimum interval is that the majority of participants in the Moderna COVID-19 vaccine clinical trial received the second dose 21 to 42 days after the first, as per the pre-defined window

Return to footnote c referrer

Footnote d

The AstraZeneca COVID-19 vaccine clinical trial demonstrated optimal efficacy when the interval between the first and second doses was ≥12 weeks

Return to footnote d referrer

Refer to Timing of Vaccine Administration in the CIG, Part 1 - Key Immunization Information for additional general information.

Extended intervals for COVID-19 vaccines to optimize early vaccine roll-out and population protection

Currently, no data on medium- or long-term efficacy of COVID-19 vaccines are available.

In general, interruption of a vaccine series resulting in a greater than recommended interval between doses does not require restarting the series as delays between doses do not result in a reduction in final antibody concentrations for most multi-dose (prime-boost) products. For many other multi-dose vaccines provided in adulthood using other vaccine technologies, the greatest proportion of short-term protection is achieved with the first dose with additional doses primarily intended to extend protection over the longer term. However, the follow-up time in COVID-19 vaccine clinical trials is short, the duration of protection after one or both is unknown, and mRNA and viral vector-based vaccines represent relatively new vaccine technologies.

Morbidity and mortality from COVID-19 is ongoing. Extending the interval to the second dose of a COVID-19 vaccine maximizes vaccine supply to immunize the largest number of people as quickly as possible. Principles of immunology indicate that a longer interval between priming and boosting doses of a vaccine series results in a better, more durable response. Please refer to Extended dose intervals for COVID-19 vaccines to optimize early vaccine rollout and population protection in Canada in the context of limited vaccine supply for a summary of the evidence.

Follow-up of vaccine effectiveness in individuals for whom the second dose is delayed or who have otherwise missed their second dose (e.g., missed a follow-up immunization appointment) will be important to inform future recommendations and ensure completion of the vaccine series as soon as possible. NACI will continue to monitor the evidence and update recommendations as needed.

Booster doses and re-immunization

There is currently no evidence on the need for booster doses of COVID-19 vaccine after the vaccine series is complete. Given the emergence of variants of concern against which vaccine effectiveness may be decreased, additional vaccine doses may be necessary. NACI will continue to monitor the evidence and update recommendations as needed.

Interchangeability

NACI recommends that the vaccine series be completed with the same COVID-19 vaccine product.

Currently, no data exist on the interchangeability of COVID-19 mRNA vaccines. However, the spike proteins encoded by either of the authorized mRNA vaccines are stabilized in the same manner to remain in the pre-fusion conformation, though other vaccine components like the lipid nanoparticle and the mRNA sequence may be different. Currently, no data exist on the interchangeability of the AstraZeneca COVID-19 vaccine with other COVID-19 vaccines.

Similarly, no data exists on the interchangeability of COVID-19 viral vector vaccines. The authorized viral vector vaccines differ in three key ways: number of doses in a complete series, SARS-CoV-2 antigen, and virus used as the vector. The AstraZeneca vaccine is a two-dose vaccine based on ChAd that encodes a wild-type, unstabilized spike protein. The Janssen vaccine is a one-dose vaccine based on Ad26 that encodes a spike protein stabilized in the prefusion conformation.

If the vaccine product used for a previously received dose is not known, or not available, attempts should be made to complete the vaccine series with a similar type of COVID-19 vaccine (e.g., mRNA vaccine and mRNA vaccine). It is not recommended that vaccines of different types (e.g., mRNA vaccine and viral vector vaccine) be used in the same series. In the context of limited COVID-19 vaccine supply and the absence of evidence on interchangeability of COVID-19 vaccines, the previous dose may be counted, and the series need not be restarted. In the event that an individual receives one dose of the AstraZeneca vaccine and is unable to receive the same type of viral vector vaccine for the second dose, receiving the Janssen vaccine would be considered as restarting a vaccine series, as one dose of the Janssen vaccine is considered to be a complete series. There is limited evidence that two heterologous COVID-19 viral vector vaccines can be used in the same seriesFootnote 23.

At this time, it is not recommended that vaccines of different types (e.g., mRNA vaccine and viral vector vaccine) be used in the same series, however, studies involving mixed schedules with different vaccines are ongoing. Recommendations on which vaccine product to complete a vaccine series in individuals who have received one dose of the AstraZeneca COVID-19 vaccine will be made immediately after evidence on mixed COVID-19 vaccine schedules is available (expected June 2021). Active surveillance of effectiveness and safety of a mixed schedule are important and these recommendations may change as further evidence becomes available. Accurate recording of vaccines received will be critical. NACI will continue to monitor the evidence and update recommendations as needed.

Refer to Principles of Vaccine Interchangeability in the CIG, Part 1 - Key Immunization Information for additional general information.

Post-vaccination counseling

NACI recommends that prophylactic oral analgesics or antipyretics (e.g., acetaminophen or ibuprofen) should not be routinely used before or at the time of vaccination, but their use is not a contraindication to vaccination. Oral analgesics or antipyretics may be considered for the management of adverse events (e.g., pain or fever, respectively), if they occur after vaccination.

Analgesics and antipyretics were used in clinical trials of COVID-19 vaccine for the management of pain and/or fever after vaccination. There is currently no evidence on the benefit from administration of oral analgesics for the prevention of immunization injection pain or systemic reactions.

All vaccine recipients should be instructed to seek medical care if they develop signs or symptoms of an allergic reaction after their observation period ends and they have left the immunization clinic/venue.

All vaccine recipients who develop symptoms compatible with COVID-19 should be tested for SARS-CoV-2 to document breakthrough illness, particularly in the context of the emergence of VOC. Genetic sequencing should be strongly considered for those with SARS-CoV-2 infection after vaccination with either one or two doses of a COVID-19 vaccine.

Anyone receiving the AstraZeneca COVID-19 vaccine should be informed of the recently recognized adverse event of Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT) and advised to seek immediate medical attention if they develop symptoms of thromboembolism and/or thrombocytopenia between days 4 and 28 following receipt of the AstraZeneca vaccine (although most occur between days 4 and 14 post-vaccine)Footnote 24. Symptoms to be vigilant for include: shortness of breath, chest pain, leg swelling, persistent abdominal pain, neurological symptoms including sudden onset of severe or persistent worsening headaches or blurred vision, skin bruising (other than at the site of vaccination) or petechiae. In addition, healthcare professionals should be aware of VITT including how to diagnose and treat the condition (see Ontario Science Table guidelines).

Refer to Vaccine Administration Practices in the CIG, Part 1 - Key Immunization Information for additional information on pre- and post-vaccination counseling.

Serological testing

Serologic testing is not needed before or after immunization with COVID-19 vaccine.

Storage requirements

Pfizer-BioNTech COVID-19 vaccine

Frozen vials prior to use

The Pfizer-BioNTech COVID-19 vaccine must be stored at ultra-low temperatures of -80°C to -60°C and protected from light, in the original packaging, until ready to use.

Refer to the re-icing guidelines (available at Pfizer-BioNTech COVID-19 Vaccine) for instructions regarding the use of the manufacturer's original thermal container for temporary storage.

Vials may also be stored at -25°C to -15°C for up to 2 weeks. Vials must be kept frozen and protected from light, in the original cartons, until ready to use. Vials stored at -25°C to -15°C for up to 2 weeks may be returned one time to the recommended storage condition of -80°C to -60°C. Total cumulative time the vials are stored at -25°C to -15°C should be tracked and should not exceed 2 weeks.

Thawed, unpunctured vials (prior to dilution)

The Pfizer-BioNTech COVID-19 vaccine may be thawed and stored at +2°C to +8°C for up to 120 hours (5 days) or at room temperature (up to +25°C) for no more than 2 hours. During storage, minimize exposure to room light, and avoid exposure to direct sunlight and ultraviolet light. Thawed vials can be handled in room light conditions.

Do not refreeze thawed vials.

Thawed, punctured vials (after dilution)

The Pfizer-BioNTech COVID-19 vaccine must be stored between +2°C to +25°C and used within 6 hours from the time of dilution. During storage, minimize exposure to room light, and avoid exposure to direct sunlight and ultraviolet light. After dilution, the vaccine vials can be handled in room light conditions.

Moderna COVID-19 vaccine

Frozen vials prior to use

The Moderna COVID-19 vaccine should be stored at temperatures of -25ºC to - 15ºC and protected from light in the original packaging. Do not store on dry ice or below -40ºC.

Thawed, unpunctured vials

If not punctured, the Moderna COVID-19 vaccine can be thawed and stored at +2°C to +8°C for up to 30 days, or at +8°C to +25°C for up to 12 hours.

Do not refreeze thawed vials.

Thawed, punctured vials

The Moderna COVID-19 vaccine can be stored between +2°C to below +25°C but must be discarded after 6 hours from the time of first puncture. During storage, vials should be protected from light.

AstraZeneca COVID-19 vaccine

Unopened multidose vial

The AstraZeneca vaccine can be stored between +2ºC to +8ºC and protected from light in the original packaging. Do not freeze.

Opened multidose vial

After first opening, chemical and physical in-use stability has been demonstrated from the time of vial puncture to administration for no more than 6 hours at room temperature (up to +30ºC) or 48 hours in a refrigerator (+2ºC to +8ºC).

After the first puncture, the vial can be re-refrigerated, but the cumulative storage time at room temperature must not exceed 6 hours, and the total cumulative storage time must not exceed 48 hours. After this time, the vial must be discarded.

Janssen COVID-19 vaccine

Unopened multidose vial

The Janssen COVID-19 vaccine can be stored between +2ºC to +8ºC and protected from light in the original packaging. Do not freeze.

Punctured multidose vial

After the first dose has been withdrawn, the vial/filled syringe can be held at 2°C to 8°C for up to 6 hours or at room temperature (maximally 25°C) for up to 3 hours, after the first puncturing of the vial. Discard if vaccine is not used within this time.

For more information, consult the product leaflet or information contained within the product monograph available through Health Canada's Drug Product Database. Refer to Storage and Handling of Immunizing Agents in the CIG, Part 1 - Key Immunization Information for additional general information.

Simultaneous administration with other vaccines

NACI recommends that COVID-19 vaccines should not be given simultaneously with other vaccines (live or inactivated).

Currently, no data exist on the simultaneous administration of COVID-19 vaccine with other vaccines. In the absence of evidence, attempts should be made to avoid simultaneous administration to maximize benefits of COVID-19 vaccination while minimizing any risks of harm, including the potential for immune interference or the erroneous attribution of an adverse event following immunization (AEFI) to a particular vaccine. However, if a COVID-19 vaccine is inadvertently administered at the same time as another vaccine, neither dose should be repeated.

In the absence of evidence, it would be prudent to wait for a period of at least 28 days after each vaccine dose of an mRNA or viral vector COVID-19 vaccine before the administration of another vaccine (except in the case where another vaccine is required for post-exposure prophylaxis) due to the elicitation of an inflammatory cytokine response. It would be prudent to wait for a period of at least 14 days after the administration of another vaccine before administrating a COVID-19 vaccine to prevent erroneous attribution of an AEFI to a particular vaccine.

Refer to Timing of Vaccine Administration in the CIG, Part 1 - Key Immunization Information for additional general information on simultaneous administration of other vaccines in general.

Vaccine safety and adverse events following immunization (AEFI)

Due to limitations in the number of participants and duration of follow-up from COVID-19 clinical trials, medium- and long-term evidence on vaccine safety is limited. However, post-licensure vaccine pharmacovigilance is ongoing and safety signals around the world are detected and communicated globally. Clinical trials of the authorized COVID-19 vaccines excluded individuals with a history of severe adverse reaction associated with a vaccine and/or severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine. However, studies are ongoing.

The following section highlights key safety and AEFI data for the authorized and available COVID-19 vaccines. For additional details regarding trial design, including study population and length of follow-up, and safety for the COVID-19 vaccines authorized for use in Canada, refer to the evidence summaries in Appendix A (for the Pfizer-BioNTech COVID-19 vaccine), Appendix B (for the Moderna COVID-19 vaccine), Appendix C (for the AstraZeneca COVID-19 vaccine), and Appendix D (for the Janssen COVID-19 vaccine). Refer to Appendix E for a summary of the frequency of AEFI for the different COVID-19 vaccine products.

Refer to Part 2 - Vaccine Safety in the CIG for definitions of AEFIs and additional general information.

Very common and common adverse events

Common adverse events are defined as those that occur in 1% to less than 10% of vaccine recipients; very common adverse events occur in 10% or more of vaccine recipients. Please see Appendix E for a summary of adverse events identified in clinical trials of authorized, available COVID-19 vaccines.

Local

Pain at the injection site is very common after administration of the currently authorized, COVID-19 vaccine. More than 40% of recipients experienced injection site pain. Redness and swelling are common or very common after administration. Localized axillary swelling and tenderness was a solicited adverse event in the Moderna COVID-19 clinical trial and was very common after administration with that vaccine. Local adverse events are usually mild or moderate and resolve within a few days of vaccination. For the authorized mRNA COVID-19 vaccines, pain at the injection site was slightly more frequent in younger adults compared to older adults. For AstraZeneca COVID-19 vaccine, local reactions were milder and reported less frequently after the second vaccine dose in all age groups.

Systemic

Fatigue, headache, muscle pain, chills, and joint pain are all either common or very common after the administration of the currently authorized, COVID-19 vaccines. Fever was very common after administration of the second dose of the mRNA COVID-19 vaccines and common after any dose of viral vector COVID-19 vaccines. More than a quarter of vaccine recipients experienced headache, and/or fatigue after any dose. For the mRNA COVID-19 vaccines, systemic adverse events are usually mild or moderate intensity and resolve within a few days of vaccination. Systemic reactions are more frequent after the second vaccine dose and in younger adults. For AstraZeneca COVID-19 vaccine, systemic reactions are milder and reported less frequently after the second vaccine dose than the first in all age groups. Similar frequencies of local reactions were reported across age groups after administration of the Janssen vaccine.

Adverse events following the second dose of COVID-19 in individuals previously infected with SARS-CoV-2

Evidence on the safety of vaccine booster doses is available from observationalFootnote 25 and clinical studiesFootnote 18 Footnote 26 Footnote 27. Occurrence of solicited and unsolicited systemic adverse events in individuals with prior SARS-CoV-2 infection was slightly higher compared to the SARS-CoV-2 naïve population, primarily in younger adults. However, there was no observed increase in the frequency of more severe adverse events in this population. Two observational studies included less than 100 patients with persistent symptoms from prior COVID-19 infections (Long COVID). In this subgroup, receipt of COVID-19 vaccination with either an mRNA or viral vector vaccine was not associated with a worsening of long COVID symptoms or increased reactogenicity following immunization.

Uncommon, rare, and very rare adverse events

Uncommon adverse events occur in 0.1% to less than 1% of vaccine recipients. Rare and very rare adverse events occur in 0.01% to less than 0.1% and less than 0.01% of vaccine recipients, respectively. The probability of detection of very rare adverse events in clinical trials is low given clinical trial population sizes; therefore, ongoing pharmacovigilance is essential.

mNRA COVID-19 vaccines

To date, the available data does not indicate that vaccination of SARS-CoV-2 naïve individuals with authorized, COVID-19 vaccines will elicit enhanced or altered disease upon subsequent infection by SARS-CoV-2 (e.g., vaccine-enhanced disease); however, further study is needed.

Lymphadenopathy was a solicited event in the Moderna clinical trials but not in other authorized COVID-19 vaccine trials (see Appendix E). It was uncommonly reported after administration of the Pfizer-BioNTech, AstraZeneca, and Janssen COVID-19 vaccines.

No other solicited uncommon, rare, or very rare adverse events were reported among vaccinated participants in the clinical trials at this time.

Thrombosis and Thrombocytopenia following Vaccination with the AstraZeneca COVID-19 vaccine

Very rare cases of serious blood clots (at unusual sites such as cerebral venous sinus thrombosis, splanchnic vein thrombosis, as well as arterial thrombosis) associated with thrombocytopenia have been reported globally following vaccination with viral vector COVID-19 vaccines. The terminology for this syndrome has been evolving since the safety signal was detected. It has been referred to as Vaccine-Induced Prothrombotic Immune Thrombocytopenia (VIPIT), Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT), and would be classified as the anti-PF4 positive subgroup within the case definition for Thrombosis with Thrombocytopenia Syndrome (TTS).

The exact mechanism by which the viral vector COVID-19 vaccines may trigger this syndrome is still under investigation but the mechanism appears to be similar to spontaneous heparin-induced thrombosis (HIT) / autoimmune heparin-induced thrombosis, where antibodies to platelet factor 4 (PF4)-polyanion complexes induce platelet activation, which causes thrombosis and thrombocytopenia. Due to the immune stimulus, and frequent occurrence of disseminated intravascular coagulation, clots related to VITT can be very aggressive and challenging to treat. They cannot be managed the same way as clots related to oral contraceptives, immobility, or long haul flights, and have an entirely different biologic mechanism of action. While thrombotic events have been rarely reported after vaccination with mRNA COVID-19 vaccines or after infection with SARS-CoV-2, most of these events have not been accompanied by thrombocytopenia or the other distinctive characteristics of VITT.

Cases of VITT usually occur between 4 and 28 days after receipt of a viral vector COVID-19 vaccine. Due to the time to onset of symptoms and diagnosis, as well as the variability in reporting, the rate of this adverse event is uncertain. The rate of VITT is estimated to be between 1 per 100,000 and 1 per 250,000 persons vaccinated with the AstraZeneca COVID-19 vaccine. This rate is evolving as cases continue to be reported and investigated, and varies between countries. The rate of VITT in Canada as of April 28, 2021 is closer to 1 per 100,000 persons vaccinated with the AstraZeneca/Covishield COVID-19 vaccine. The case fatality rate of VITT also varies between countries, and ranges between 20 and 40%. Many cases have been reported to have serious long-term morbidity, including neurologic injury. Reports of adverse events that closely resemble VITT after administration of the Janssen vaccine are emerging from the United States. As of April 28, 2021, 17 cases have been confirmed after 8 million doses of Janssen vaccine administered in the United States, and others are under investigation.For more information, see Appendix C, Appendix D, Appendix F, and NACI rapid response: Recommended use of AstraZeneca COVID-19 vaccine in younger adults.

Guidance on reporting adverse events following immunization (AEFI)

Vaccine providers are asked to report AEFIs through local public health departments and to follow AEFI reporting requirements that are specific to their province or territory. In general, any serious (defined as resulting in hospitalization, permanent disability or death) or unexpected adverse event that is temporally related to vaccination should be reported.

In addition to provincial or territorial reporting requirements, the Brighton Collaboration has developed a list of Adverse Events of Special Interest (AESI) that are of particular interest and should be reported. Refer to Brighton Collaboration: COVID-19 for the list with definitions.

There may be additional very rare AEFIs that have not been detected through clinical trials to date.

Refer to Adverse Events Following Immunization (AEFI) in the CIG, Part 2 - Vaccine Safety for additional information on definitions, reporting, investigating and managing, and causality assessments for AEFIs.

Refer to Reporting Adverse Events Following Immunization (AEFI) in Canada for additional information on the completion and submission of AEFI reports.

Refer to the AEFI weekly report for more information on the reported adverse events following COVID-19 vaccination in Canada

Contraindications and precautions

Rare anaphylactic reactions have been reported following immunization with mRNA COVID-19 vaccines.

Table 4 lists potential non-medicinal ingredients in authorized, available COVID-19 vaccines that have been associated with allergic reactions in other products. These reactions have occurred rarely, and ranged from mild cutaneous reactions to anaphylaxis. Anaphylaxis is typically a rare, severe, life-threatening allergic reaction usually with a rapid onset that involves multiple organ systems and can progress rapidly. Symptoms and signs of anaphylaxis may include, but are not limited to: generalized urticaria; wheezing; swelling of the mouth, tongue, and throat; difficulty breathing; vomiting; diarrhea; hypotension; decreased level of consciousness; and shock. It is important to note that other, less serious reactions may mimic allergic reactions (e.g., vasovagal syncope) and vaccination is not contraindicated in these cases.

Table 4: Ingredients of authorized COVID-19 vaccines that have been associated with allergic reactions in other products
Vaccine product Potential allergen included in the vaccine or its container Other products where the potential allergen may be found*
Pfizer-BioNTech COVID-19 vaccine polyethylene glycol (PEG)Footnote a Footnote b Footnote c Over the counter (e.g., cough syrup, laxatives), and prescription medications, medical bowel preparation products for colonoscopy, skin care products, dermal fillers, cosmetics, contact lens care solutions, products such as ultrasound gelFootnote d.
Moderna COVID-19 vaccine PEGFootnote a Footnote b Footnote c Over the counter (e.g. cough syrup, laxatives), and prescription medications, medical bowel preparation products for colonoscopy, skin care products, dermal fillers, cosmetics, contact lens care solutions, products such as ultrasound gelFootnote d.
tromethamineFootnote e. (trometamol or Tris) Component in contrast media, oral and parenteral medications.
AstraZeneca COVID-19 vaccine polysorbate 80Footnote c. medical preparations (e.g., vitamin oils, tablets, and anticancer agents), cosmeticsFootnote d Footnote f.
Janssen COVID-19 vaccine polysorbate 80Footnote c. medical preparations (e.g., vitamin oils, tablets, and anticancer agents), cosmeticsFootnote d Footnote f.

N.B. This is not a complete list of products.

Footnotes

Footnote a

Medications that contain PEG are described in Stone CA, et al., DOI:10.1016/j.jaip.2018.12.003

Return to footnote a referrer

Footnote b

A review of immediate type hypersensitivity reactions to PEG is available in Wenande et al, DOI: 10.1111/cea.12760

Return to footnote b referrer

Footnote c

There is a potential of cross-reactive hypersensitivity between PEG and polysorbates

Return to footnote c referrer

Footnote d

PEG is an additive in some food and drinks but allergic reactions to PEG in food or drinks have not been documented.

Return to footnote d referrer

Footnote e

One case report of anaphylaxis to tromethamine has been described (Lukawska et al, DOI: 10.1016/j.jaip.2018.08.035).

Return to footnote e referrer

Footnote f

Case reports of anaphylaxis to polysorbate 80 have been described (Badiu et al, DOI: 10.1136/bcr.02.2012.5797, Palacios Castaño et al, DOI: 10.18176/jiaci.0109).

Return to footnote f referrer

Rare cases of VITT have been reported following immunization with the the COVID-19 viral vector vaccines. Investigations are ongoing and the recommendations will be updated as evidence becomes available. For more information, refer to Appendix C, Appendix D and NACI rapid response: Recommended use of AstraZeneca COVID-19 vaccine in younger adults.

Contraindications

Anaphylaxis and Allergies to a COVID-19 vaccine

An authorized COVID-19 vaccine should not be offered routinely to individuals with a history of severe allergic reaction (e.g., anaphylaxis) after previous administration of a COVID-19 vaccine using a similar platform (mRNA or viral vector). If a risk assessment deems that the benefits outweigh the potential risks for the individual; and if informed consent is provided, an authorized COVID-19 vaccine using a different platform may be considered for re-immunization (i.e., individuals with anaphylaxis post mRNA vaccine may be offered a viral vector vaccine and individuals with anaphylaxis post viral vector vaccine may be offered a mRNA vaccine). If immunization with a different platform is offered, individuals should be observed for at least 30 minutes after immunization.

An authorized COVID-19 vaccine should not be routinely offered to individuals with a proven severe allergic reaction (e.g., anaphylaxis) to any component of the specific COVID-19 vaccine or its container.

For a comprehensive list of components in the vaccine and packaging, please consult the product leaflet or information contained within the product monograph available through Health Canada's Drug Product Database.

Thrombosis and Thrombocytopenia following vaccination

Patients who have experienced major venous or arterial thrombosis with thrombocytopenia following vaccination with a viral vector COVID-19 vaccine should not receive a second dose of a viral vector COVID-19 vaccine.

Precautions

Hypersensitivity and Allergies

If a risk assessment deems that the benefits outweigh the potential risks for the individual; and if informed consent is provided; vaccination may be considered in individuals with mild to moderate immediate allergic reactions (defined as limited in the scope of symptoms and involvement of organ systems or even localized to the site of administration) after a previous dose of authorized COVID-19 vaccines or any of its components. Assessment by a physician or nurse with expertise in immunization may be warranted prior to re-immunization. Most instances of anaphylaxis to a vaccine begin within 30 minutes after administration of the vaccine. Therefore, if vaccination is chosen, an extended period of observation post-vaccination of at least 30 minutes should be provided for the aforementioned individuals.

Individuals with proven severe allergic reaction (e.g., anaphylaxis) to injectable therapy not related to a component of authorized COVID-19 vaccines (e.g. intramuscular, intravenous, or subcutaneous vaccines or therapies) may be routinely vaccinated and do not need to be assessed. Most instances of anaphylaxis to a vaccine begin within 30 minutes after administration of the vaccine. Therefore, an extended period of observation post-vaccination of 30 minutes should be provided for the aforementioned individuals.

Individuals with suspected but unproven allergy to a vaccine component (e.g. PEG) may be routinely vaccinated and do not need a specific assessment regarding this suspected allergy. Most instances of anaphylaxis to a vaccine begin within 30 minutes after administration of the vaccine. Therefore, an extended period of observation post-vaccination of 30 minutes should be provided for the aforementioned individuals.

Individuals with a history of allergy not related to a component of authorized COVID-19 vaccines or other injectable therapy (e.g. foods, oral drugs, insect venom or environmental allergens) can receive COVID-19 vaccines without any special precautions. Individuals should be observed for a minimum of 15 minutes following vaccination.

Acute illness

Vaccination of individuals who may be currently infected with SARS-CoV-2 is not known to have a detrimental effect on the illness. However, vaccination should be deferred in symptomatic individuals with confirmed or suspected SARS-CoV-2 infection, or those with respiratory symptoms, in order to avoid attributing any complications resulting from SARS-CoV-2 infection to vaccine-related AEFI and to minimize the risk of COVID-19 transmission at an immunization clinic/venue. If any persons are identified with symptoms on arrival at the venue, they should be instructed to follow current local public health measures.

As a precautionary measure and in light of the need to be able to monitor for COVID-19 vaccine adverse events without potential confounding from symptoms of COVID-19 or other co-existing illnesses, one should wait until all symptoms of an acute illness are completely resolved before vaccinating with an authorized COVID-19 vaccine.

Pregnancy

The safety and efficacy of authorized COVID-19 vaccines in pregnancy have not yet been established, however safety data are accumulating from post marketing surveillance. Pregnant individuals were excluded from the mRNA and viral vector COVID-19 vaccine clinical trials. Currently, there are limited data on the safety of COVID-19 vaccine from animal developmental and reproductive toxicity studies. In rats that received the Moderna COVID-19 vaccine prior to or during gestation, no safety concerns regarding female reproduction, fetal/embryonal development, or postnatal development were demonstrated. According to a report presented to the European Medicines Agency (EMA), studies in rats using four full doses of the Pfizer-BioNTech COVID-19 vaccine did not indicate adverse effects with respect to fertility, pregnancy, embryo/fetal development, or postnatal development, up to day 21. Developmental and Reproductive Toxicity (DART) animal studies for the AstraZeneca COVID-19 vaccine are ongoing. A US Food and Drug Administration (FDA) review of a study in rabbits that received the Janssen COVID-19 vaccine at two times the human dose prior to or during gestation concluded there were no adverse effects on female reproduction, fetal/embryonal development, or postnatal development.

Hematologic

In individuals with bleeding disorders, the condition should be managed prior to immunization to minimize the risk of bleeding. Individuals receiving long-term anticoagulation are not considered to be at higher risk of bleeding complications following immunization and may be safely immunized without discontinuation of their anticoagulation therapy.

Thrombosis and Thrombocytopenia

Individuals who have experienced a previous CVST with thrombocytopenia or heparin-induced thrombocytopenia (HIT) should only receive a viral vector COVID-19 vaccine if the potential benefits outweigh the potential risks. An alternate COVID-19 vaccine should be offered.

Anyone receiving any authorized viral vector COVID-19 vaccine should be informed of the risk of VITT and advised to seek immediate medical attention if they develop symptoms of VITT. These symptoms may include: shortness of breath, chest pain, leg swelling or pain, or persistent abdominal pain following vaccination. Additionally, anyone with neurological symptoms after vaccination including sudden onset of severe headaches, persistent or worsening headaches, blurred vision, confusion or seizures, or who experiences unusual skin bruising or petechiae beyond the site of vaccination after a few days, should seek prompt medical attention.

Refer to Contraindications, Precautions and Concerns in the CIG, Part 2 - Vaccine Safety for additional general information.

Drug interactions

There have been no drug interactions studies performed to date.

For more information about potential interactions with products containing anti-SARS-CoV-2 antibodies, refer to section Blood products, human immunoglobulin and timing of immunization, in this Statement.

Tuberculin skin testing (TST) or interferon gamma release assay (IGRA)

There is a theoretical risk that mRNA or viral vector vaccines may temporarily affect cell-mediated immunity, resulting in false-negative TST or IGRA test results. If tuberculin skin testing or an IGRA test is required, it should be administered and read before immunization or delayed for at least 4 weeks after vaccination. Vaccination with COVID-19 vaccines may take place at any time after all steps of tuberculin skin testing have been completed.

In cases where an opportunity to perform the TST or IGRA test might be missed, the testing should not be delayed since these are theoretical considerations. However, re-testing (at least 4 weeks post immunization) of individuals with negative results for whom there is high suspicion of TB infection may be prudent in order to avoid missing cases due to potentially false-negative results.

Blood products, human immunoglobulin and timing of immunization

NACI recommends that COVID-19 vaccines should not be given simultaneously with monoclonal antibodies or convalescent plasma.

To date, there is insufficient evidence on the receipt of both a COVID-19 vaccine and anti-SARS-CoV-2 monoclonal antibodies or convalescent plasma for treatment or prevention. Therefore, timing of administration and potential interference between these two products are currently unknown. Administration of these products close together may result in decreased effectiveness of a COVID-19 vaccine and/or anti-SARS-CoV-2 monoclonal antibodies because the monoclonal antibodies have high affinity for the spike protein expressed by the vaccines, which could prevent the production of antibodies stimulated by the vaccine.

In the post-exposure setting, expert clinical opinion should be sought on a case-by-case basis when deciding whether anti-SARS-CoV-2 monoclonal antibodies would be appropriate to administer after receipt of COVID-19 vaccine, taking into consideration the risk of exposure and the risk of severe COVID-19 disease in the individual.

To date, there is also insufficient evidence on the receipt of both a COVID-19 vaccine and any monoclonal antibodies or convalescent plasma for treatment or prevention of non-COVID-19 disease. Therefore, timing of administration and potential interference between these two products are currently unknown and expert clinical opinion should be sought on a case-by-case basis.

Recommendations

Following the thorough review of available evidence summarized above, as well as the systematic assessment of ethics, equity, feasibility and acceptability considerations with the EEFA FrameworkFootnote 2 as summarized in NACI's Guidance on Key Populations for Early COVID-19 Immunization, NACI makes the following evidence-informed recommendations for public health program level decision-making for the effective and equitable use of COVID-19 vaccines authorized and available for use in Canada.

NACI will continue to carefully monitor the scientific developments related to COVID-19 and COVID-19 vaccines, as well as ongoing vaccine pharmacovigilance, and will update recommendations as required.

Please note:

Please see Table 5 for a more detailed explanation of the strength of NACI recommendations.

Recommendations on authorized, available COVID-19 vaccines

These recommendations apply only to COVID-19 vaccines currently authorized for use in Canada (Pfizer-BioNTech COVID-19 vaccine; Moderna COVID-19 vaccine; AstraZeneca COVID-19 vaccine; and Janssen COVID-19 vaccine). In considering these recommendations and for the purposes of publicly funded program implementation, provinces and territories may consider local programmatic factors (e.g., logistical and operational contexts, resources) and local epidemiology (e.g., transmission of SARS-CoV-2 VOC).

  1. NACI preferentially recommends that a complete series with an mRNA COVID-19 vaccine should be offered to individuals in the authorized age group without contraindications to the vaccine. If an mRNA vaccine is contraindicated, another authorized COVID-19 vaccine should be offered. (Strong NACI Recommendation)

  2. NACI recommends that a complete series with a viral vector COVID-19 vaccine may be offered to individuals 30 years of age and older without contraindications ONLY if the individual prefers an earlier vaccine rather than to wait for an mRNA vaccine AND all of the following conditions apply:

    1. The benefit-risk analysis* determines that the benefit of earlier vaccination with the viral vector COVID-19 vaccine outweighs the risk of COVID-19 while waiting for an mRNA COVID-19 vaccine; and
    2. The benefits, relative risk* and consequences of VITT and COVID-19 for the individual are clearly outlined, factoring in the anticipated waiting time to receive an mRNA vaccine as well as other effective personal public health measures to mitigate risk of COVID-19, and the individual makes an informed decision based on an understanding about these risks and benefits; and
    3. There will be substantial delay to receive an mRNA vaccine.

Note: Provinces and territories should adapt the age limit based on their local epidemiology.
(Discretionary NACI Recommendation)

* See Risk Assessment Tool below and Management Options Table to assist with this determination

Risk Assessment Tool for the use of of viral vector COVID-19 vaccines

The benefit-risk analysis for vaccination with the a viral vector COVID-19 vaccines while an authorized mRNA COVID-19 vaccine is temporarily unavailable or inaccessible, may vary between jurisdictions and individuals and will depend on various factors, summarized in the table below:

Risk Assessment Tool for the use of of viral vector COVID-19 vaccines
Factors that may vary between jurisdictions and individuals ConsiderationsFootnote 1

Local COVID-19 epidemic conditions

  • The benefit of viral vector COVID-19 vaccines increases in regions of moderate, high or very high epidemic transmission or in regions with ncreasing incidence rates, where immediate protection is needed to prevent symptomatic disease and preserve health system capacity.
  • Consider local transmission potential for viral variants of concern and anticipated protection against them.

Local vaccine supply

  • Consider how long an individual will need to wait to be offered an mRNA vaccine, based on expected vaccine supply and priority group.

Risk of severe illness and death

Risk of exposure

Logistical considerations

  • Although the viral vector COVID-19 vaccines are refrigerator-stable, which makes these vaccines easier to store and handle, infrastructure now exists to support the use of ultra-frozen and frozen mRNA vaccines.
  • The Janssen COVID-19 vaccine is authorized as a single dose; however, the duration of protection of one dose is unknown.

Risk of VITT

  • The rate of this adverse event has been estimated to be between 1/100,000 and 1/250,000 persons vaccinated with the AstraZeneca COVID-19 vaccine, however this rate is evolving as cases continue to be reported and investigated. The estimate in Canada as of April 28, 2021 is closer to 1/100,000. The case fatality rate typically ranges between 20 and 40%. Other predisposing factors for VITT are unclear.
  • Evidence of this adverse event after vaccination with the Janssen COVID-19 vaccine is emerging in the United States. As of April 28, 2021, 17 cases have been confirmed after 8 million doses of the Janssen vaccine administered. Most of these cases were in female between 18 and 59 years of age, however additional cases are under investigation. Initial cases of VITT after vaccination with AstraZeneca COVID-19 vaccine were also seen in younger females; however, reports of VITT in older adults and in males have more recently been confirmed. The risk of developing VITT after receipt of the AstraZeneca COVID-19 vaccine does not seem to be related to age or sex.

Vaccine characteristics

  • Emerging data suggests that all authorized COVID-19 vaccines offer protection against hospitalization and likely also death from COVID-19.
  • Results from clinical trials of mRNA vaccines suggest superior efficacy against symptomatic COVID-19 disease compared to the viral vector vaccines.
  • There is evidence that both the Pfizer-BioNTech and AstraZeneca vaccines protect against the B.1.1.7 SARS-CoV-2 variant. In studies in South Africa, the Janssen vaccine was shown to offer protection against the B.1.351 SARS-CoV-2 variant, while the AstraZeneca vaccine was shown not to offer protection against that variant of concern. In studies in Brazil, the Janssen vaccine was shown to offer protection against the P.2 variant.
  • Early evidence suggests that the Pfizer-BioNTech vaccine has moderate to high effectiveness against asymptomatic infection, with some evidence of protection available for Moderna and Janssen as well. Early evidence suggests that the AstraZeneca vaccine may not be efficacious against asymptomatic infections.

Access to diagnosis and treatment for COVID-19 and VITT

  • Consider healthcare system capacity, access to tertiary and ICU care, as well as IVIG for treatment of VITT.

Risk of exacerbating inequities

  • The use of viral vector COVID-19 vaccines may increase inequities for individuals with limited ability to reduce their personal risk of infection or who work in occupations with direct close physical contact with the public, and due to the complexities of making an informed choice with regard to the risk and benefits of earlier vaccination with the viral vector COVID-19 vaccines.
  • Consider the impact of exacerbating inequities in these populations, many of whom belong to marginalized and disadvantaged groups disproportionately affected by the pandemic.
Footnote 1

NACI is monitoring evolving evidence

Return to footnote 1 referrer

Refer to the Management options table for COVID-19 vaccines authorized for use in Canada for a summary of evidence and factors for jurisdictions to consider when implementing COVID-19 immunization programs.

Summary of evidence and rationale:

mRNA COVID-19 vaccines

AstraZeneca COVID-19 vaccine

  1. Based on emerging evidence of the protection provided by the first dose of a two-dose series for COVID-19 vaccines currently authorized and available in Canada, NACI recommends that in the context of limited COVID-19 vaccine supply and ongoing pandemic disease, jurisdictions should maximize the number of individuals benefiting from the first dose of vaccine by extending the second dose of COVID-19 vaccine up to four months after the first. Second doses should be offered as soon as possible after all eligible populations have been offered first doses, with priority given to those at highest risk of severe illness and death from COVID-19 disease. Vaccinated people (with one or two doses) should continue to follow recommended public health measures. NACI will continue to monitor the evidence on effectiveness of an extended dose interval and will adjust recommendations as needed. (Strong NACI Recommendation)

Please see NACI's Statement on Extended dose intervals for COVID-19 vaccines to optimize early vaccine rollout and population protection in Canada in the context of limited vaccine supply for a summary of the evidence and further rationale for this recommendation.

  1. NACI recommends that all individuals should continue to practice recommended public health measures for prevention and control of SARS-CoV-2 infection and transmission regardless of vaccination with COVID-19 vaccine, at this time. (Strong NACI Recommendation)

    Summary of evidence and rationale:

  1. NACI recommends that a complete series with a COVID-19 vaccine may be offered to individuals in the authorized age group without contraindications to the vaccine who have had previously PCR-confirmed SARS-CoV-2 infection. In the context of limited vaccine supply, initial doses may be prioritized for those who have not had a previously PCR-confirmed SARS-CoV-2 infection. (Discretionary NACI Recommendation)

    Summary of evidence and rationale:

NACI also makes the following recommendations for COVID-19 immunization in some specific populations who were either excluded from or were represented by small numbers of participants in clinical trials. Vaccine may be offered to some individuals in these populations in some circumstances on a case-by-case basis with a risk-benefit analysis (where the risk of exposure and/or severe COVID-19 disease outweighs the risk of vaccination), and with transparency about the limited evidence. Preference for mRNA COVID-19 vaccine (as outlined in Recommendation #1, above), if available, also applies to the populations described below.

NACI will be reassessing these recommendations as more evidence has become available.

Immunosuppressed persons

  1. NACI recommends that a complete COVID-19 vaccine series may be offered to individuals who are immunosuppressed due to disease or treatment in the authorized age group in this population, if a risk assessment deems that the benefits outweigh the potential risks for the individual, and if informed consent includes discussion about the limited evidence on the use of COVID-19 vaccines in this population and the possibility that individuals who are immunosuppressed may have a diminished immune response to any of the authorized COVID-19 vaccines. (Discretionary NACI Recommendation)

    Summary of evidence and rationale:

Refer to Immunization of Immunocompromised Persons in the CIG, Part 3 - Vaccination of Specific Populations for definitions and general additional information.

Persons with an autoimmune condition

  1. NACI recommends that a complete vaccine series with a COVID-19 vaccine may be offered to individuals with an autoimmune condition in the authorized age group in these populations if a risk assessment deems that the benefits outweigh the potential risks for the individual, and if informed consent includes discussion about the insufficiency of evidence on the use of COVID-19 vaccines in these populations. (Discretionary NACI Recommendation)

    Summary of evidence and rationale:

Refer to Immunization in Persons with Chronic Diseases in the related section in the CIG, Part 3 - Vaccination of Specific Populations for additional general information on autoimmune conditions.

Pregnancy and breastfeeding

  1. NACI recommends that a complete vaccine series with a COVID-19 vaccine (preferably with an mRNA COVID-19 vaccine)Footnote ** may be offered to pregnant individuals in the authorized age group if a risk assessment deems that the benefits outweigh the potential risks for the individual and the fetus, and if informed consent includes discussion about the evidence on the use of COVID-19 vaccines in this population. (Discretionary NACI Recommendation)

    Footnote **

    An mRNA vaccine is preferred due to published safety data and concerns about treatment of VITT in pregnancy, should it occur. Recently published preliminary analyses of 35,691 pregnant women in the United States who received an mRNA COVID-19 vaccine did not reveal any obvious safety signals 29. If VITT were to occur after receipt of a viral vector vaccine in a pregnant person, there is increased complexity in the medical care.

    Return to footnote ** referrer

  2. NACI recommends that a complete vaccine series with a COVID-19 vaccine may be offered to individuals in the authorized age group who are breastfeeding, if a risk assessment deems that the benefits outweigh the potential risks for the individual and the infant, and if informed consent includes discussion about the limited evidence on the use of COVID-19 vaccines in this population. (Discretionary NACI Recommendation)

    Summary of evidence and rationale:

Refer to Immunization in Pregnancy and Breastfeeding, Part 3 - Vaccination of Specific Populations of the CIG for additional general information.

Children and adolescents

  1. NACI recommends that COVID-19 vaccines should not be offered routinely to individuals who are not in the authorized age group. (Strong NACI Recommendation)

    1. However, a complete vaccine series with a Pfizer-BioNTech may be offered to individuals 12-15 years of age who are at very high risk of severe outcomes of COVID-19 (e.g., due to a pre-existing medical condition known to be associated with increased risk of hospitalization or mortality) or are at increased risk of exposure (e.g., due to living in a congregate care facility), if a risk assessment deems that the benefits outweigh the potential risks for the individual, and if informed consent with the individual and the parent or guardian includes discussion about the limited evidence on the use of COVID-19 vaccines in this population. (Discretionary NACI Recommendation)

    Summary of evidence and rationale:

NACI continues to recommend the following:

Refer to Vaccine Safety and Pharmacovigilance in the CIG, Part 2 - Vaccine Safety for additional information.

NACI continues to recommend the following elements to guide ethical decision-making, as outlined in NACI's guidance on Key Populations for Early COVID-19 Immunization:

Management options for COVID-19 vaccines authorized for use in Canada

There are currently four authorized COVID-19 vaccines in Canada for the prevention of symptomatic COVID-19 that use two different vaccine platforms. To assist with the decision on which vaccine to offer to different populations or groups, a comparison of the relative merits of both have been summarized in Table 5 below. Caution should be taken when comparing vaccines due to differences in studies conducted for each vaccine (e.g., different endpoints, different analyses, different time periods/countries and circulating strains).

Table 5 : Management options for types of COVID-19 vaccines authorized for use in Canada
Factor for consideration Summary of available evidence and issues for consideration
mRNA COVID-19 Vaccines viral vector COVID-19 Vaccines

Efficacy and Effectiveness*

Efficacy against symptomatic illness after a complete series

  • Pfizer-BioNTech vaccine is overall 94% efficacious ≥14 days after dose 2 in study participants 18 years of age and older.
  • Data suggests the Pfizer/BioNTech vaccine is 95% efficacious in participants ≥65 years of age 7 or more days after dose 2.
  • Moderna vaccine is overall 94% efficacious in participants 18 years of age and older ≥14 days after dose 2.
  • Data suggests the Moderna vaccine is 86% efficacious in individuals ≥65 years of age.

Effectiveness against severe disease, hospitalization and death

  • Current data from real-world studies suggests that mRNA COVID-19 vaccines provide good protection against COVID-19 hospitalization >14 days after the first dose, including in older populations (≥65 years).
  • Data from real-world studies provide some evidence that the first dose of mRNA COVID-19 vaccines provide very good protection against COVID-19-related death.
  • Limited data from real-world studies suggests the Pfizer-BioNTech COVID-19 vaccine has high vaccine effectiveness >7 days after the second dose against severe disease and COVID-19 related hospitalization and death.

Effectiveness data on the Moderna COVID-19 vaccine alone is not currently available.

Efficacy against symptomatic illness after a complete series

  • AstraZeneca SD/SD vaccine is 62% efficacious in participants 18 to 64 years of age.
  • Current data from clinical trials are insufficient to determine the efficacy of the AstraZeneca vaccine in individuals ≥65 years of age.
  • The interval between the first and second dose of the AstraZeneca vaccine may impact efficacy of the vaccine, with lower efficacy if the interval is less than 12 weeks.
  • The Janssen COVID-19 vaccine (1 dose) is 66.9% and 66.1% efficacious against confirmed symptomatic moderate to severe/critical COVID-19 infection at ≥14 days and ≥28 days post-vaccination, respectively.
  • The Janssen COVID-19 vaccine is 76.7% and 85.4% efficacious against confirmed symptomatic severe/critical COVID-19 infection at ≥14 days and ≥28 days post-vaccination, respectively.

Effectiveness against symptomatic illness and hospitalization

  • Observational data in individuals ≥65 years of age have shown a reduction in the risk of symptomatic disease and hospitalization with one dose of AstraZeneca vaccine.
  • Effectiveness data on the Janssen COVID-19 vaccine is not currently available.

Efficacy against asymptomatic infection

  • A preliminary analysis of limited data in an ongoing trial suggests the Moderna COVID-19 vaccine may be efficacious in preventing asymptomatic infection, however data is still being collected and the final analysis is not complete.

Effectiveness against asymptomatic infection

  • Estimates of vaccine effectiveness for the Pfizer-BioNTech COVID-19 vaccine against SARS-CoV-2 infection with no reported symptoms was moderate to high after the first dose (depending on time since vaccination) and high after the second doseFootnote 9 Footnote 15. Similar results were reported for mRNA COVID-19 vaccines in generalFootnote 16.

Efficacy against asymptomatic infection

  • An exploratory ad hoc analysis of limited data suggests the AstraZeneca vaccine may not be efficacious in preventing asymptomatic infection.
  • Preliminary analyses of limited data suggests that the Janssen COVID-19 vaccine has an estimated efficacy of 59.7% against asymptomatic or undetected SARS-CoV-2 infection with onset ≥28 days post-vaccination.

Re-vaccination

  • It is not yet clear if booster doses (e.g., annual vaccination) will be required to provide long-term protection against symptomatic COVID-19 disease, in particular with the emergence of variants of concern.
  • Re-vaccinating those who initially received an mRNA vaccine with the same or another mRNA vaccine is currently being investigated.
  • The efficacy and safety of re-vaccinating those who initially received mRNA vaccine with a different COVID-19 vaccine are unknown at this time but are being investigated

Re-vaccination

  • It is not yet clear if booster doses (e.g., annual vaccination) will be required to provide long-term protection against symptomatic COVID-19 disease, in particular with the emergence of variants of concern
  • Re-vaccination with a booster dose of viral vector vaccines may reduce vaccine effectiveness due to the possible development of immunity to the viral vector which may interfere with the immune response to subsequent doses. However, this is still being investigated.
  • The efficacy and safety of re-vaccinating those who initially received a viral vector vaccine with a different COVID-19 vaccine are unknown at this time

Immunogenicity

Humoral response

  • Humoral responses for both mRNA COVID-19 vaccines in clinical trials peaked after a second dose, including elicitation of neutralizing antibodies. However, as a correlate of protection is not known, these humoral responses cannot be interpreted as corresponding with protection.
  • Humoral responses in clinical trials had similar trends in individuals 18 to 55 years of age and individuals 65 to 85 years of age.
  • In observational studies, humoral responses in seropositive vaccine recipients after the first dose were comparable to those observed in SARS-COV-2 naïve individuals following administration of the second dose. However, as a correlate of protection is not known, the significance of these findings as they relate to the level of protection against reinfection is unknownFootnote 17 Footnote 18 Footnote 19 Footnote 20 Footnote 21 Footnote 22.

Humoral response

  • For the AstraZeneca vaccine, humoral responses in clinical trials peaked after a second dose, including elicitation of neutralizing antibodies, for seronegative vaccine recipients. For seropositive vaccine recipients, humoral responses peaked at the first dose and maintained or decreased at the second dose.
  • For the AstraZeneca vaccine, humoral responses in clinical trials were lower in individuals ≥65 years of age and older, compared to individuals 18 to 64 years of age in unpublished data presented to NACI. Conflicting results have been shown for other age groups in recently published dataFootnote 30.
  • However, as a correlate of protection is not known, these humoral responses cannot be interpreted as corresponding with vaccine protection.
  • For the Janssen vaccine, humoral responses in clinical trials, including binding antibodies, neutralizing antibodies and antibodies with Fc effector functions, were seen by day 29 after one dose.
  • For the Janssen vaccine, somewhat lower humoral immune responses were seen in older age cohorts (>65) compared to younger cohorts (18 to 55) in clinical trials.
  • However, as a correlate of protection is not known, these humoral responses cannot be interpreted as corresponding with vaccine protection.

Cellular response

  • Both mRNA vaccines have been shown to produce a cellular immune response by one to two weeks after administration of a second dose.
  • Increases in cellular immune responses response were seen in both younger and older adults.
  • As no immunological correlate of protection has been determined for SARS-CoV-2, these cellular responses cannot be interpreted as corresponding with vaccine protection.

Cellular response

  • The AstraZeneca vaccine has been shown to produce cellular immune responses that did not appear to increase after the second dose.
  • Cellular immune responses do not appear to differ between age groups.
  • For the Janssen vaccine, cellular immune responses were elicited after one dose of vaccine.
  • As no immunological correlate of protection has been determined for SARS-CoV-2, these cellular responses cannot be interpreted as corresponding with vaccine protection.

Protection against variants, including variants of concern

B.1.1.7 (identified in UK)

  • In countries where B.1.1.7 was the dominant circulating strain (>90% of sequenced samples), estimates of vaccine effectiveness of the Pfizer-BioNTech vaccine were comparable to vaccine efficacy against the parent strain.

B.1.351 (identified in South Africa)

  • There are emerging data on the efficacy or effectiveness of mRNA vaccines against B.1.351.

P.1 and P.2 (identified in Brazil)

  • There are limited data on the efficacy or effectiveness of mRNA vaccines against P.1 and P.2.

B.1.1.7 (identified in UK)

  • Data suggest AstraZeneca vaccine has a vaccine efficacy against B.1.1.7 that is comparable to that against non-B.1.1.7 disease (74.6% vs. 84.1% respectively)Footnote 31.

B.1.351 (identified in South Africa)

  • Data suggest AstraZeneca vaccine has a vaccine efficacy of 10.4% against B.1.351 against mild to moderate illnessFootnote 32.
  • In South Africa, where B.1.351 was the dominant strain (approximately 95% of preliminary sequenced samples), the Janssen vaccine was 64% efficacious against moderate to severe/critical COVID-19 as of Day 29.

P.1 and P.2 (identified in Brazil)

  • There are limited data on the efficacy or effectiveness of viral vector vaccines against P.1.
  • In Brazil, where P.2 was detected in approximately 70% of sequenced samples of COVID-19 cases, the Janssen vaccine was 68% efficacious against moderate to severe/critical COVID-19 as of Day 29.

Safety

Technology

  • mRNA vaccines use a new technology (which has been studied in experimental vaccines); however, all COVID-19 vaccines undergo the same rigorous review and approval process as routine vaccines.

Technology

  • Viral vector vaccines use a relatively new technology (the authorized Ebola vaccine uses this technology); however, all COVID-19 vaccines undergo the same rigorous review and approval process as routine vaccines.

Safety Signals

  • There have been no serious safety signals identified with either mRNA vaccine. Rare anaphylactic reactions have been reported following immunization with mRNA COVID-19 vaccines.
  • For both vaccines, some solicited adverse events are reported to be very common (defined as 10% or more) among vaccine recipients; however, they are mild or moderate and transient, resolving within a few days. These include: pain at the injection site, fatigue, headache, muscle pain, chills, joint pain, and fever. Some adverse events, including fever, are more frequent after the second dose.

Safety Signals

  • For both vaccines, some solicited adverse events are reported to be very common (defined as 10% or more) among vaccine; however, they are mild or moderate and transient, resolving within a few days. These include: pain at the injection site, fatigue, headache, muscle pain, chills, joint pain, and fever. Some adverse events are less frequent after the second dose.
  • For the AstraZeneca vaccine, rare cases of thrombosis and thrombocytopenia have been reported during post-licensure use. The mechanism of action appears to be similar to spontaneous heparin-induced thrombocytopenia (called VITT- Vaccine-Induced Immune Thrombotic Thrombocytopenia). The rate of this adverse event is still to be confirmed but had been most commonly estimated to be between 1/100,000 and 1/250,000 people vaccinated with AstraZeneca vaccine. The estimate in Canada as of April 28, 2021 is closer to 1/100,000. The case fatality rate typically ranges between 20 and 40%. Other predisposing factors for VITT are unclear.
  • For the Janssen vaccine, in the clinical trial, one case of cerebral venous thrombosis was reported among 21,895 vaccine recipients. As of April 28, 17 cases of VITT have been confirmed out of 8 administered in the United States. Investigations are ongoing.

Ethics and Equity

  • mRNA vaccines have high short-term efficacy in all authorized age groups and Canada anticipates having enough doses of mRNA vaccines for every individual in Canada in 2021.
  • Vaccines that are more efficacious may be directed to those who are most at risk of severe disease and exposure to limit the exacerbation of existing inequities.
  • The impact of not offering a less efficacious vaccine earlier to populations who would otherwise have to wait to receive an mRNA vaccine in areas with a high risk of transmission and infection, should take into consideration trust, justice, and the risk of doing harm vs good.
  • Offering any COVID-19 vaccine to those who would otherwise have to wait to receive one could enhance equity.
  • If protection against COVID-19 disease cannot be boosted for those that received a lower efficacy vaccine first, significant inequities could be created for those who receive a viral vector vaccinevaccine compared to an mRNA vaccine, depending on which population groups received the viral vector vaccine.
  • The viral vector vaccines may offer an option for individuals who are allergic to mRNA vaccine ingredients or their containers. The impact of offering a less efficacious vaccine earlier to some populations should take into consideration trust, justice and the risk of doing harm vs. good.

Feasibility

Vaccine schedule

  • Both mRNA vaccines are given as a two-dose series.
  • The mRNA vaccines have an authorized schedule of 21 (for the Pfizer vaccine) or 28 days (for the Moderna vaccine) between dose one and dose two. NACI has recommended an extended interval between the first and second dose of up to 4 months to maximize the number of individuals who can be vaccinated as quickly as possible with available vaccine supplies. This could allow for more individuals to receive one dose of the vaccine and have some protection against symptomatic COVID-19 disease.

Vaccine schedule

  • The AstraZeneca vaccine is given as a two-dose series.
  • The interval between the first and second dose of the AstraZeneca vaccine seems to impact efficacy of the vaccine, with lower efficacy if the interval is less than 12 weeks.
  • NACI has recommended an extended interval between the first and second dose of up to 4 months to maximize the number of individuals who can be vaccinated as quickly as possible with available vaccine supplies.
  • The Janssen vaccine is authorized as a single dose. This may increase the feasibility of the completion of a vaccine series.
  • Vaccine recipients need to be advised of the VITT safety signal and the symptoms to watch for after vaccination.

Storage requirements

  • The mRNA vaccines have more challenging transport and storage requirements, requiring frozen or ultra-frozen cold chains. Significant efforts have been undertaken to address these logistical complexities. The storage requirements for these vaccines increase the logistical complexity of offering these vaccines in some venues to increase access for various populations.

Storage requirements

  • The viral vector vaccines are easier to transport, store and handle than mRNA vaccines, and as a result, could be easier to use for wider distribution via pharmacies and primary healthcare providers.
  • The viral vector vaccines require storage and transport at +2 to +8°C, which uses standard cold chain infrastructure widely available in provinces and territories.
  • The storage requirements for these vaccines could increase access to the vaccine for various populations.

Acceptability

  • It is possible that individuals will favor mRNA vaccines since they have higher proven efficacy.
  • Fewer cases of COVID-19 are expected after vaccination with a vaccine with high efficacy. The relatively low incidence of cases post-vaccination could positively affect acceptability of COVID-19 vaccines and vaccines in general
  • It is possible that individuals will favor the viral vector vaccines if it offers an earlier opportunity to receive a COVID-19 vaccine and is more convenient to access if they are available at more convenient locations due to ease of transport, storage and handling.
  • A greater number of COVID-19 cases are expected after vaccination with a vaccine that has lower efficacy. The relatively higher incidence of cases post-vaccination could negatively affect the public's acceptability of COVID-19 vaccines and vaccines in general.
  • The Janssen vaccine is given as a single dose. This may increase acceptability of vaccination.
  • Recent cases of VITT detected after administration with the viral vector vaccines have impacted their acceptability.

Concerns about vaccine safety and effectiveness are the two most cited reasons for vaccine refusalFootnote 33

  • In a survey of Canadians conducted between February 9 and 16, 2021Footnote 34, the following results were reported:
    • Of those who indicated they have not yet been vaccinated (n=1954), more respondents 'Agreed' or 'Strongly Agreed' with items stating intention to get a 'safe vaccine' (69%) and an 'effective vaccine' (67%) since Wave 4 (late May-early June).
    • When respondents who were willing or neutral towards getting vaccinated were asked what is most important with respect to selecting a COVID-19 vaccine to receive (n=1595), 46% selected "Receiving the most effective vaccine", 15% selected "Receiving any vaccine as soon as possible" and 12% selected "Receiving the vaccine with the fewest reported side effects". The number of doses and type of vaccine technology were not important factors, and 14% of respondents indicated they have no preference on what COVID-19 vaccine they receive.
    • For those who will wait to get the vaccine once it is available: 80% will wait to ensure the safety of the vaccine, 64% will wait to ensure the effectiveness of the vaccine (n=691)Footnote 35
  • In a survey of health care providers conducted on Dec 4-13, 2020Footnote 36, the: most important factors reported to influence the decision to receive vaccine were vaccine safety (95.5%), followed by vaccine effectiveness (86.7%)% (n=14,336)

Research priorities

COVID-19 disease and associated vaccines are novel; therefore, research is warranted in many areas. Research to address the following outstanding questions (not ordered in terms of importance) is encouraged, drawing from both short-term and long-term data, where available:

New and emerging research priorities

Efficacy, effectiveness, immunogenicity and safety

  1. What is the population effectiveness (against infection/transmission, hospitalization and death) and medium and long-term duration of protection of a single dose or a complete series of each COVID-19 vaccine approved in Canada?
  2. What is the efficacy, effectiveness, immunogenicity, and safety of COVID-19 vaccines across diverse population groups (e.g., adults of advanced age, those with high-risk medical conditions including autoimmune conditions and transplant recipients, individuals with social or occupational vulnerabilities, individuals who are pregnant or breastfeeding, children/adolescents, frailty)?
  3. What is the efficacy, effectiveness, immunogenicity and safety of COVID-19 vaccines in individuals who have had a previous laboratory evidence of SARS-CoV-2 infection?
    1. Is there a discernable difference between seronegative and seropositive people in any of the above parameters?
    2. Does previous exposure to SARS-COV-2 impact efficacy, effectiveness, immunogenicity or safety of COVID-19 vaccines?
    3. Can a single-dose vaccine series be as effective and safe in individuals with previously proven COVID-19 disease?
    4. Are there any emerging safety signals with COVID-19 immunization that are not predicted by the current understanding of the safety profile of similar vaccines?
    5. Does vaccination following prior SARS-CoV-2 infection or vaccination of SARS-CoV-2 naïve individuals elicit enhanced or altered disease upon subsequent infection by SARS-CoV-2 or other endemic coronaviruses?
  4. What is the efficacy, effectiveness, immunogenicity and safety of COVID-19 vaccines (including potential boosters) against SARS-CoV-2 variants of concern?
  5. What is the correlate of protection for SARS-CoV-2? How are immune responses induced by natural infection similar or different from those induced by vaccines against COVID-19? Is SARS-CoV-2 natural infection (symptomatic or asymptomatic) associated with protection against re-infection or severe disease?
  6. Further immunological evidence is needed in the following areas to inform efficacy predictions:
    1. How do immune responses change over time; what is the durability of immune responses against SARS-COV-2 over the long-term? What is the impact of vaccine dose or interval on durability?
    2. Which immune responses are most important for protection from infection (adaptive or innate immunity), severe disease or transmissibility? What is the role of humoral vs. cellular immunity in preventing immune escape of viral variants?
    3. Are immunoglobulin (Ig)A/IgG/IgM antibodies protective against SARS-CoV-2 and what is the correlate of protection?
  7. What level of COVID-19 vaccination coverage is required to achieve various public health milestones, including: coverage to reduce the burden on the health care system to a manageable degree, achieve herd immunity to protect non-vaccinated individuals, and remove PHM controls. What vaccine characteristics play the largest role on these milestones (i.e., efficacy, durability, uptake)?
  8. What is the background level of Canadian vaccine-vector-specific responses (i.e., anti-Chimpanzee adenovirus)? Are these responses higher in some groups? Will these responses interfere with vaccine efficacy of these highly seropositive groups? What is the duration of anti-vector interference immunity following viral vector vaccines?
  9. How will viral variants impact the efficacy, effectiveness, immunogenicity and safety of a vaccine with respect to death, severe disease, symptomatic disease, asymptomatic disease, infectivity and transmission? What is the effect of using booster vaccines containing heterologous antigens and what is the optimal timing for booster vaccination?
  10. Are any components of the COVID-19 vaccine at high risk of inducing an anaphylactic reaction?
  11. What is the incidence of rare, serious adverse events following immunization with COVID-19 vaccines?
    1. What is the incidence of thrombosis and thrombocytopenia including CVST and DIC after COVID-19 immunization and after infection with SARS-CoV-2? What is the trigger for the development of this adverse event following immunization and what can be done to mitigate its development?
    2. What is the exact biological mechanism by which viral vector vaccines may trigger VITT? Are VITTs a class effect of the adenovirus vector vaccines or are there separate mechanisms that are product-specific (e.g., due to differing dose and magnitude of immune response based on the nature of the vaccines)?
    3. How do age, sex, or other patient characteristics (e.g., pregnancy, health-seeking behaviours) affect the incidence of VITT and the complications of VITT?
  12. Does endemic coronavirus infection history impact the course of SARS-CoV-2 disease? Is there cross-protection or interference from antibodies/exposure to human seasonal coronaviruses when exposed to SARS-CoV-2 or vaccinated against SARS-CoV-2?
  13. Are there any negative interactions between COVID-19 vaccination and other medications? What is the recommended timing between COVID-19 vaccines and anti-SARS-CoV-2 prophylactic or therapeutic antibodies or convalescent plasma?
  14. Does vaccination have an impact on the transmissibility of SARS-CoV-2 in individuals with asymptomatic infection?
  15. What is the role of seasonal attenuation of SARS-CoV-2?
  16. How does vaccination impact individual-level variation in transmission (e.g., superspreaders)?
  17. What is the epidemiology of SARS-CoV-2 variants of concern over time and across the country and its regions? What are the transmissibility and virulence (including hospitalizations and deaths) of the variants of concern?
  18. What are the epidemiological characteristics of breakthrough illness (e.g., vaccine recipient characteristics, SARS-CoV-2 variants of concern)?

Vaccine administration

  1. Are any COVID-19 vaccines interchangeable to complete a regular vaccine series? What is the efficacy, effectiveness, immunogenicity and safety of a mixed dose schedule or a mixed dose booster series?
  2. What are the minimum, maximum, and optimal intervals between doses of a two-dose COVID-19 vaccine schedule that continue to provide protection against disease?
  3. Are any other vaccines (e.g., Bacillus Calmette-Guérin) protective against COVID-19 through off-target effects?
  4. Can COVID-19 vaccine be simultaneously administered with other, non-COVID-19 vaccines (either live or inactivated vaccines)? If not, what is the minimum interval between administrations?
  5. Can COVID-19 vaccines be given in individuals who have received convalescent plasma or anti-SARS-CoV-2 spike protein monoclonal antibodies? If so, what is the minimum interval required for vaccine administration following receipt of convalescent plasma or monoclonal antibodies?

Standing research priorities

COVID-19 infection and disease

  1. What is the epidemiological profile of COVID-19 (e.g., communicable period, all risk groups)?
    1. What is the disease distribution and spectrum of clinical illness for COVID-19, including burden of illness and risk by age, sex and other demographic variables associated with higher risk?
    2. What are the transmission dynamics of COVID-19, including degree of asymptomatic transmission, role of children in transmission, vertical transmissibility, onset and duration of viral shedding and communicable period, impact of changing weather conditions, and trends over time?
    3. What are the rates of COVID-19 co-infections with other respiratory pathogens and what is the impact on pathogenesis and clinical outcomes?
  2. Can COVID-19 vaccine be used to protect household contacts of a case from infection? Does COVID-19 vaccination decrease infectiousness and clinical illness in individuals that have already acquired infection? Is COVID-19 vaccination effective in interrupting transmission?

Ethics, equity, feasibility and acceptability

  1. What is the acceptability of (a) publicly funded COVID-19 vaccines and other vaccines over time and over different epidemiological contexts among key populations, marginalized populations, providers and policy-makers in different epidemiological contexts across the country?
    1. What factors affect acceptability of immunization with a COVID-19 vaccine in these groups?
    2. What factors affect acceptability of immunization in general?
    3. How will acceptability of prioritized key populations for early immunization with COVID-19 vaccines evolve in different epidemiological contexts across the country?
    4. What strategies can improve acceptability of a COVID-19 vaccine in these groups?
  2. How can vaccine allocation decisions be communicated to individuals and communities in order to maintain trust in public health authorities?
  3. What COVID-19 vaccination strategies or implementation strategies can reduce health inequities in populations for whom the vaccination program is directly intended, and in populations for whom the vaccination program is not intended, but who are still impacted by it (e.g., impacted by the disease, spillover effects such as for caregivers, or externalities such as with herd immunity)?
  4. Can a different COVID-19 vaccine be used to complete a primary series or as a booster dose? How are returning travelers managed if they have initiated but not completed a COVID-19 vaccine series abroad?

Health-related quality of life and well-being

  1. What is the health-related quality of life or well-being of COVID-19 patients and caregivers over time (e.g., health utilities, patient-reported outcomes, patient-reported experiences measures)?
  2. What is the impact of COVID-19 vaccination on health-related quality of life or well-being on individuals?

Surveillance issues

Ongoing and systematic data collection, analysis, interpretation and timely dissemination is fundamental to planning, implementation, evaluation, and evidence-informed decision-making. To support such efforts, NACI encourages surveillance improvements in the following areas:

1. Epidemiology

2. Laboratory (e.g., strain characterization)

3. Vaccine (coverage, effectiveness, safety)

Table 6: Strength of NACI recommendations
Strength of NACI recommendation based on factors not isolated to strength of evidence (e.g., public health need) Strong Discretionary
Wording "should/should not be offered" "may/may not be offered"
Rationale Known/anticipated advantages outweigh known/anticipated disadvantages ("should"), or Known/Anticipated disadvantages outweigh known/anticipated advantages ("should not") Known/anticipated advantages are closely balanced with known/anticipated disadvantages, or uncertainty in the evidence of advantages and disadvantages exists
Implication A strong recommendation applies to most populations/individuals and should be followed unless a clear and compelling rationale for an alternative approach is present. A discretionary recommendation may/may not be offered for some populations/individuals in some circumstances. Alternative approaches may be reasonable.

List of abbreviations

Ad26
Modified human adenovirus 26
AE
Adverse event
AEFI
Adverse event following immunization
ARCHE
Alberta Research Center for Health Evidence
CDC
Centres for Disease Control and Prevention (United States)
ChAd
Chimpanzee Adenovirus
CI
Confidence interval
CIC
Canadian Immunization Committee
CIG
Canadian Immunization Guide
COVID-19
Coronavirus disease 2019
CVST
Cerebral venous sinus thrombosis
DART
Developmental and Reproductive Toxicity
DIC
Disseminated intravascular coagulation
EEFA
Ethics, Equity, Feasibility, and Acceptability
EMA
European Medicines Agency
FDA
Food and Drug Administration (US)
GRADE
Grading of Recommendations, Assessment, Development and Evaluation
HIV
Human immunodeficiency virus
ICU
Intensive care unit
IM
Intramuscular
Ig
Immunoglobulin
IGRA
Interferon gamma release assay
JCVI
Joint Committee on Vaccination and Immunisation (UK)
MAAE
Medically attended adverse event
MenACWY
Quadrivalent meningococcal vaccine
mRNA
messenger ribonucleic acid
NACI
National Advisory Committee on Immunization
NITAG
National Immunization Technical Advisory Group
PCR
Polymerase chain reaction
PHAC
Public Health Agency of Canada
SAE
Serious adverse events
SAGE
Strategic Advisory Group of Experts on Immunization (WHO)
SARS-CoV-2
Severe acute respiratory syndrome coronavirus 2
SD
Standard dose
SII
Serum Institute India
SOC
System organ class
TST
Tuberculin skin test
TTS
Thrombosis with Thrombocytopenia Syndrome
UK
United Kingdom
US
United States
VIPIT
Vaccine -Induced Prothrombotic Immune Thrombocytopenia
VITT
Vaccine-Induced Immune Thrombotic Thrombocytopenia
VOC
Variants of Concern
VPD
Vaccine preventable disease
WHO
World Health Organization

Acknowledgments

This statement was prepared by: SJ Ismail, K Young, MC Tunis, A Killikelly, R Stirling, O Baclic, J Zafack, M Salvadori, N Forbes, L Coward, C Jensen, R Krishnan, Y-E Chung, B Warshawsky, E Wong, K Farrah, A Nam, A Sinilaite, MW Yeung, S Deeks, and C Quach on behalf of the High Consequence Infectious Disease Working Group (HCID WG) and was approved by NACI.

NACI gratefully acknowledges the contribution of: C Mauviel, K Ramotar, V Ferrante, S Pierre, E Tice, A Sinilaite, L Whitmore, J Shurgold, J Vachon, J Macri, J Mielczarek, R Goddard, B Sader, M Patel, A House, and the Alberta Research Centre for Health Evidence and the PHAC Public Health Ethics Consultative Group.

NACI

Members: C Quach (Chair), S Deeks (Vice-Chair), J Bettinger,, P De Wals, E Dubé, V Dubey,, R Harrison, K Hildebrand, K Klein, J Papenburg, C Rotstein, B Sander, S Smith, and S Wilson.

Liaison representatives: LM Bucci (Canadian Public Health Association), E Castillo (Society of Obstetricians and Gynaecologists of Canada), A Cohn (Centers for Disease Control and Prevention, United States), L Dupuis (Canadian Nurses Association), J Emili (College of Family Physicians of Canada), D Fell (Canadian Association for Immunization Research and Evaluation), M Lavoie (Council of Chief Medical Officers of Health), D Moore (Canadian Paediatric Society), M Naus (Canadian Immunization Committee), and A Pham-Huy (Association of Medical Microbiology and Infectious Disease Canada).

Ex-officio representatives: D Danoff (Marketed Health Products Directorate, HC), E Henry (Centre for Immunization and Respiratory Infectious Diseases [CIRID], PHAC), M Lacroix (Public Health Ethics Consultative Group, PHAC), J Pennock (CIRID, PHAC), R Pless (Biologic and Radiopharmaceutical Drugs Directorate, Health Canada), G Poliquin (National Microbiology Laboratory, PHAC), V Beswick-Escanlar (National Defence and the Canadian Armed Forces), and T Wong (First Nations and Inuit Health Branch, Indigenous Services Canada).

NACI High Consequence Infectious Disease Working Group

Members: C Quach (Chair), S Deeks (Vice-Chair), Y-G Bui, K Dooling, R Harrison, K Hildebrand, M Miller, M Murti, J Papenburg, R Pless, S Ramanathan, N Stall, and S Vaughan.

PHAC Participants: N Abraham, P Doyon-Plourde, K Farrah, V Ferrante, N Forbes, SJ Ismail, A Killikelly, A Nam, M Patel, A Sinilaite, E Tice, MC Tunis, MW Yeung, K Young, and L Zhao.

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