Samir Sinha (Department of Medicine, University of Toronto; National Institute on Ageing, Ryerson University) @DrSamirSinha
Cameron Feil (National Institute on Ageing, Ryerson University) @Cameron_Feil
Natalie Iciaszczyk (National Institute on Ageing, Ryerson University) @Natalie_Ici
In early November 2020, prior to the arrival of its first vaccines, Canada’s National Advisory Committee on Immunization (NACI) recommended that the first stage of immunizations be given to residents, staff and family caregivers in Long-Term Care (LTC), retirement homes and other congregate settings for older persons, adults over 70, health-care workers, and adults in Indigenous communities. NACI reaffirmed this in its subsequent COVID-19 vaccination prioritization guidelines initially released in December 2020 and then updated in February 2020 and summarized in Figure 1.
Figure 1: Summary of Canadian NACI Recommendations on the Prioritization of Key Populations for COVID-19 Immunization
Under the Canada Health Act, jurisdictional responsibility for the provision of health care falls to the provinces and territories. Each has released their own corresponding vaccination rollout strategies based on their individual priorities that now include vaccinating all LTC residents and staff by February 2021. Additionally, five provinces and one territory – Newfoundland, British Columbia, Nova Scotia, Prince Edward Island (PEI), Ontario, and Nunavut – have also included family caregivers of LTC residents as part of the initial populations being prioritized for vaccination.
Of the 2,841,710 doses of the Pfizer-BioNTech and Moderna vaccines that the federal government has delivered to each of Canada’s provinces and territories on an equal per capita basis, 80.4% of these doses had been reportedly administered as of March 9, 2021. While each province had received sufficient vaccine doses by late December to deliver initial doses to their entire LTC populations, which total at least 211,000 individuals, differences in vaccine rollout strategies have resulted in large discrepancies in LTC residents, staff, and family caregivers vaccination across Canada. On February 26, 2021, the federal government announced that it had approved the AstraZeneca COVID-19 vaccine. However, NACI is not currently recommending the use of this vaccine yet for people over the age of 65, including those residing in LTC settings, as the Pfizer and Moderna mRNA vaccines offer “superior efficacy”.  Furthermore, on March 5, 2021, the federal government announced that it had approved the Johnson and Johnson COVID-19 vaccine, yet NACI has yet to make a recommendation for its use.
Table 1: Long-Term Care Vaccine Coverage by Canadian Provinces and Territories
Table 1 presents Canada’s current progress in vaccinating its LTC residents and staff. As of February 27, 2021, 85.29% residents of Canadian LTC homes have received at least one dose of the COVID-19 vaccine. However, this figure is likely an underestimate due to both reporting methods and how Canada’s provinces and territories are defining their LTC populations .
Eight provinces and territories: Quebec (January 8th), Prince Edward Island (January 15th), Alberta (January 17th), Saskatchewan (January 21st), Yukon Territory (January 26th), British Columbia (January 29th), Manitoba (January 29th), North West Territories (February 3rd) and Ontario (February 14th) have confirmed offering first-dose vaccinations to 100% of their LTC home populations [8,9,10, 17, 18, 27,30]. Two provinces have yet to offer all LTC residents and staff vaccines, but have reported the proportion of the population accepting at least one dose. This includes New Brunswick (86%) coverage, Nova Scotia (40.5%) coverage. One province and one territory: Newfoundland, and Nunavut – have yet to publicly release detailed data or regular updates pertaining to their LTC vaccination programs.
Quebec recently reported that 92% of its LTC residents have accepted a first dose of the COVID-19 vaccine, a small increase from the 87% rate reported in January. More concerningly, it noted that only 40% of its LTC staff had accepted a first dose of the COVID-19 vaccine. In British Columbia, 95% of its LTC residents and 89% of staff accepted the first dose of COVID-19 vaccine. Saskatchewan reported that 91% of LTC residents accepted the first dose of the vaccine. Ontario has reported that 89% of its LTC residents have accepted the first dose of COVID-19 vaccine. On the other hand, as of this week, only 55% of Ontario’s long-term care staff have volunteered to get their first dose, despite being the first population in the province invited to receive the COVID-19 vaccine .
Understanding the Inconsistent Approaches to Vaccinating Canadian LTC Populations
A critical reason for the fragmented rollout across Canada’s LTC settings has been how their provinces/territories had originally set up their vaccine distribution programs. The northern territories and more rural and remote settings of Canada’s provinces are relying on the use of the more easily transportable Moderna vaccine which only began to be delivered to the provinces and territories at the end of December to vaccinate their LTC residents. Some initial concerns about the ability to transport the Pfizer-BioNTech vaccine into LTC settings meant that some provinces like Ontario decided to prioritize its use via hospital distribution centres where able bodied LTC staff and family caregivers could receive their vaccine while waiting to use the Moderna vaccine for its LTC residents.
Pfizer, however, provided broadened transportation guidelines to the Public Health Agency of Canada (PHAC) on December 18, 2020 on how to safely transport its vaccine into LTC settings. As a result, Quebec established half of its initial vaccination centres in its LTC settings to facilitate resident vaccinations with the Pfizer-BioNTech and BC quickly adjusted its rollout strategy to begin moving its larger supply of this vaccine into LTC homes by December 23, 2020, to get its LTC residents vaccinated. On the other hand, Ontario which initially decided against bringing its Pfizer-BioNTech vaccines directly into LTC settings began to do so as of January 5th as it began to face widespread criticism around its slow vaccination rollout in its LTC settings. In Ontario, there had been concern around how it initially prioritized certain frontline and non-LTC frontline health care workers over LTC residents and staff that worsened its ability to vaccinate LTC residents efficiently especially as subsequent vaccine shortages emerged; whilst in Manitoba, concerns had been reported regarding its in initial approach to support the vaccination of LTC home-dwelling individuals.
Regional differences around the speed at which provincial and territorial LTC populations were vaccinated quickly emerged. As of January 5, 2021 fewer than 4,000 (5.5%) of Ontario’s 72,000 LTC residents had been given an initial dose of the Pfizer-BioNTech or Moderna vaccine, and over 26,000 (26%) of its more than 100,000 LTC staff. British Columbia, by comparison, had given a first dose to over 4,700 (20%) of its LTC residents and 11,600 (50%) of its LTC staff by January 4, 2021.
Moreover, even in provinces where vaccination efforts in its LTC settings have appeared to be comprehensive, many residents and staff have in reality been left out. For example, in Alberta, while 100% of 27,000 residents in publicly funded LTC facilities have been vaccinated, 10,000 residents of exclusively private ‘undesignated’ LTC and retirement homes were not included in its initial or first stage of the vaccine rollout because the death toll in these settings has been deemed to be ‘less heavy’ compared to those of publicly funded LTC settings. Regardless, all LTC settings have collectively represented 66% of Alberta’s death toll, where 73% of LTC settings have experienced at least one COVID-19 outbreak, the most of any other province in Canada. On February 19, 2021, Alberta announced that it had offered all residents of its publicly funded LTC homes two doses of the COVID-19 vaccines, and that it will now be prioritizing vaccinations for its 10,000 residents of privately funded LTC and retirement homes who are still unvaccinated as well as older persons 75 years of age and older living in the community. 
It was revealed on January 28, 2021 that the Ontario government had been inadvertently providing data on the number of doses administered to achieve full vaccination when reporting on the number of Ontarians who have been vaccinated with both doses of either the Pfizer-BioNTech or Moderna vaccine. As a result, reporting on the number of people fully vaccinated in Canada’s most populous province in January had been double the true number. While the government claimed that the number of fully vaccinated people exceeded 96,000 earlier in the week of January 25th, the total number of people who have received both doses was in reality only 55,286 as of January 28th. The province’s early inability to properly monitor its vaccination rollout not only raised questions about what else the Ontario government has been inaccurately reporting over the course of the pandemic, but also further undermined efforts to track vaccination coverage at the national level.
Ontario’s vaccine rollout in its LTC homes has been the most haphazard across Canada. In mid-January, the Ontario Government indicated that its lack of incoming vaccines would not affect its LTC resident populations, stating that they would prioritize any remaining vaccine towards offering first-dose vaccinations to 100% of its LTC residents by February 15, 2021. While most of Canada’s largest provinces had already accomplished offering their LTC residents a first-dose of the COVID-19 vaccine by the week of January 25, 2021 a modelling study released around this time by the Ontario Government’s Science Table helped to underscore the value of vaccinating all LTC residents as soon as possible. In their study, they noted that if Ontario had prioritized getting all of its LTC residents vaccinated by January 31, 2021 vs February 15, 2021 would help to avert at least 600 new COVID-19 infections and 115 deaths by March 31, 2021. As a result of this study, the Ontario Government announced on January 25th that it would speed up its target to administer an initial vaccine dose to all of its LTC home residents by 10 days with a new target completion date of February 5, 2021. Ongoing delays in receiving more vaccines, however, led the Ontario government to announce on February 2, 2021 that it would be unable to meet their target that 100% of LTC home residents and staff in the province be offered their first dose of a COVID- by February 5, 2021 and thus delayed its target date by 5 days to February 10, 2021. . The following day the government rescinded this statement due to a “internal miscommunication”, vowing to complete first dose vaccination in the coming days  and later announced that 89% of LTC residents and 70% of LTC staff had actually been vaccinated. In reality, 0.8 % of homes had yet to complete administering first doses . On February 14, 2021 the Ontario government reported that every LTC resident in Ontario had been offered an initial dose of the vaccine while close to half of its 70,000 residents had now received their second dose. Ontario’s Science Table COVID-19 Advisory conducted a follow up study, evaluating the impact of vaccination on LTC residents and staff. It found that eight weeks after the start of vaccinations, the relative reduction in COVID-19 incidence was estimated at 89% in LTC residents and 79% in LTC staff. In addition, the estimated reduction in COVID-19 related deaths among LTC residents was 96% after 8 weeks . The report also notes that vaccines alone are not responsible for the reduction in COVID-19 incidence in LTC homes; COVID-19 vaccinations acted “synergistically” with the range of public health measures implemented to protect residents and staff in LTC settings. The report also highlights the need to increase vaccination uptake among LTC staff, noting a significant gap in vaccine uptake between unionized health care worker and LTC staff. The report citesr targeted behavioral interventions, information campaigns, and the need for paid leave time for staff as mechanisms to increase vaccine uptake among staff. Slow-downs to Canada’s expected Pfizer-BioNTech and Moderna vaccine shipments from Europe caused no new deliveries during the week of January 25, 2021, and much reduced deliveries expected in subsequent weeks. This caused all of Canada’s provinces and territories to revise their vaccine rollout-strategies, with some considering delaying the administration of second doses. On February 10, 2021 the Federal Government’s Military Commander overseeing the national COVID-19 vaccine distribution announced that Pfizer-BioNTech would still deliver almost 1.8 million doses of their COVID-19 vaccine to Canada over the coming month. As of the week of February 15, 2021, vaccine deliveries have now resumed and are expected to ramp up quickly so that every Canadian who wants a COVID-19 vaccine will be able to receive it by September 2021.
Concerns over the delay of vaccine shipments meant that Quebec LTC residents who had already received the first dose of the Pfizer vaccine were becoming increasingly at risk of not receiving a second dose within the recommended 90 day period . However, an analysis by the Institut National de Santé du Québec (ISNPQ) found that an initial 80% level of vaccine efficacy among vaccinated LTC home residents and workers had been achieved . On February 19, 2021, the British Columbia Center for Disease Control released preliminary findings on the effectiveness of vaccines in LTC homes, also reporting 80% efficacy among residents and staff . Further, both British Columbia and Quebec have been able to greatly reduce COVID-19 outbreaks in their LTC settings over the past month. As of February 11, 2021, Quebec LTC homes were averaging six new cases a day, a 10-fold decrease from the beginning of January 2021.  While in British Columbia, there has been a 80% reduction in COVID-19 cases in its LTC homes over the same time period. . On March 2nd, the Alberta premier said that outbreaks in LTC facilities have declined by more than 95% since December . The rapidly declining numbers of COVID-19 in LTC homes in both provinces support evidence that their early vaccination efforts, in combination with strong infection prevention and control measures, were greatly reducing COVID-19 transmission and deaths across their LTC populations.
On March 7, 2021 an LTC home in Kelowna, British Columbia reported 12 total COVID-19 infections; 10 to residents, and two staff, despite 82% of its residents having received a COVID-19 vaccine. On March 9, 2021 an LTC home in Surrey, British Columbia reported 2 total COVID-19 infections; 1 resident, and 1 staff, despite 88% of its residents having received a COVID-19 vaccine . British Columbia’s Provincial Officer of Health, Dr. Bonnie Henry stated “This serves to remind us that, while we are confident vaccines are very effective and prevent severe illness and death, it doesn’t necessarily mean that all transmission will be stopped.”  Prior to the British Columbia outbreaks, two LTC homes in Quebec also experienced outbreaks after receiving vaccines in January and February 2021  . It is believed that a full immune response was not yet developed among vaccinated residents and staff, allowing the infection to spread among both residents and staff. These examples highlight that vaccine coverage is not a ‘magic bullet’ – and should be paired with strong infection prevention and control measures to protect those living and working in LTC facilities.
Finally, another issue which is coming to light is that while over 90% of LTC residents appear to be accepting a COVID-19 vaccine, varying levels of vaccine hesitancy are seeing highly variable uptake ranging from 20-70% and less than 50% overall uptake by staff in some settings, especially across Ontario and Quebec. Numerous reports highlight vaccine hesitancy among staff in LTC settings stemming from concerns about vaccine safety and efficacy [6,21,22]. A survey in British Columbia found that just over half (57%) of LTC staff wanted to get the COVID-19 vaccination . In Quebec, only 40% of LTC staff have been vaccinated due to concerns over the availability of the Pfizer vaccine . Additional problems such as employers asking LTC workers to take unpaid leave to get vaccinated may be contributing to low vaccination rates . Overall, a comprehensive information campaign targeting front-line workers could have proactively addressed questions about the benefits and risks of the vaccine and combated misinformation, ultimately reducing hesitancy among a group that has faced some of the highest risks during the pandemic. Thus far early reports show that British Columbia that has more actively addressed these issues has vaccinated 89% of their LTC staff while Ontario and Quebec have only vaccinated 55% and 40% of their LTC staff as of February 19th, 2021.[21, 38]. While New Brunswick has reported that only 55% of LTC staff accepted the COVID-19 vaccine, citing mis-information as the main determinants of the poor uptake among staff .
More recently, provinces and territories have begun to release strategies focused on priority populations beyond residents and staff of LTC – as over 85% of people living in congregate settings have been vaccinated. Provinces such as Alberta, British Columbia, Manitoba, Prince Edward Island and Quebec are booking appointments for people aged 80 and 70 years and older, depending on the province. This has allowed some LTC homes to begin resuming resident activities. For example, Chester Village, a LTC home in Toronto is permitting resident interaction through dining and games nights, although interactions are confined to residents living on the same floor . Provinces such as New Brunswick, and Nova Scotia are unable to move forward with their vaccination strategies due to logistical issues such as vaccine and staffing shortages. Overall, discrepancies between provincial jurisdiction vaccine rollouts in LTC settings are leading to fragmented vaccination coverage across Canada . Furthermore, the Canadian government announced that an additional 1.5 million doses of the Pfizer vaccine will be delivered in March, and that accelerated shipments are expected in April and May. This increase in Pfizer vaccine will help to ensure that all residents and staff in LTC settings are vaccinated as soon as possible. 
Sinha S, Feil C and Iciaszczyk N. The rollout of the COVID-19 vaccines in care homes in Canada as of 16th February 2021. Article in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE.
 National Advisory Committee on Immunization (NACI) December 12, 2020. Recommendations on the use of COVID-19 vaccine(s). Accessed Jan 30th at: https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/recommendations-use-covid-19-vaccines/december-12-2020.html
 Statistic Canada. Type of Collective Dwelling (16), Age (20) and Sex (3) for the Population in Collective Dwellings of Canada, Provinces and Territories, 2016 Census. Accessed Jan 24th at: https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/dt-td/Rp-eng.cfm?LANG=E&APATH=3&DETAIL=0&DIM=0&FL=A&FREE=0&GC=0&GID=0&GK=0&GRP=0&PID=109537&PRID=0&PTYPE=109445&S=0&SHOWALL=0&SUB=0&Temporal=2016&THEME=116&VID=0&VNAMEE=&VNAMEF=&wbdisable=true
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 Nathan M. Stall et al. on behalf of the Ontario COVID-19 Science Advisory Table. ‘The Impact of the Speed of Vaccine Rollout on COVID-19 Cases and Deaths in Ontario Long-Term Care Homes’. January 21, 2021. Accessible at: https://doi.org/10.47326/ocsat.2021.02.08.1.0
 “All LTC Residents, Staff in BC Offered COVID-19 Vaccination”
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 Ontario Plans to Accelerate Vaccination of Residents of Long-Term Care
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 The Globe and Mail. Quebecs Race to Vaccinate All Long Term Care Residents. February 11th 2021.
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 PEI Long Term Care Vaccination. January 15, 2021. https://www.cbc.ca/news/canada/prince-edward-island/pei-long-term-care-vaccines-end-of-january-1.5865373
 Reason to Celebrate Early Evidence Suggest Vaccines Halting COVID Outbreaks in Nursing Homes. February 10, 2021. https://nationalpost.com/news/canada/reason-to-celebrate-early-evidence-suggests-vaccines-halting-covid-outbreaks-in-nursing-homes
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TABLE 1.0 Data Sources:
Total # of LTC and Retirement Homes and % of Homes Affected by COVID-19 Outbreaks: NIA LTC COVID-19 Tracker Accessible at: https://ltc-covid19-tracker.ca/
Provincial/Territorial Vaccination Rates: