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 2021 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 6,864,609 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, 79.3% of these doses had been reportedly administered as of March 30, 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 resulted in large early discrepancies in LTC residents, staff, and family caregivers vaccination efforts across Canada. On February 26, 2021, the federal government announced that it had approved the AstraZeneca COVID-19 vaccine. However, NACI did not originally recommend the use of this vaccine for people over the age of 65, including those residing in LTC settings, as the Pfizer and Moderna mRNA vaccines offered “superior efficacy”. . Since then, NACI has issued new guidelines recommending the use of the Astrazeneca vaccine only for adults aged 55 and over. NACI cites that the risk-benefit ratio of not vaccinating adults aged 55 and over is too great given the high rate of COVID-19-related hospitalization and death among this age group . However, both the Pfizer and Modern vaccines will continue to be prioritized for LTC residents and older adults. 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 presents Canada’s current progress in vaccinating its LTC residents and staff. As of March 20, 2021, 91.05% 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 .
Ten 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), Ontario (February 14th), and Newfoundland and Labrador (February 26th) have confirmed offering first-dose vaccinations to 100% of their LTC home populations [8,9,10, 17, 18, 27,30]. New Brunswick and Nova Scotia have yet to offer all LTC residents and staff vaccines, but have reported either the total number or proportion of residents receiving at least one dose. In New Brunswick, 11,259 residents have received at least one dose (total number of LTC residents unknown), while this figure is 74% in Nova Scotia. 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 91% 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 95% of its LTC residents have accepted the first dose of COVID-19 vaccine. On the other hand, only 75% 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 provinces/territories originally set up their vaccine distribution programs. The northern territories and more rural and remote regions in Canada’s provinces are relying on the more easily transportable Moderna vaccine. However, deliveries of the Moderna vaccine to the provinces and territories only arrived at the end of December, officially launching Canada’s LTC vaccination rollout. 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. Similarly,BC quickly adjusted its rollout strategy to begin moving its larger supply of the Pfizer-BioNTech vaccine into LTC homes by December 23, 2020 and get its LTC residents vaccinated. On the other hand, while Ontario Initially decided against bringing its Pfizer-BioNTech vaccines directly into LTC settings, it began to do so as of January 5, 2021in response to widespread criticism around its slow vaccination rollout in its LTC settings. In Ontario, there had been concern around how certain frontline and non-LTC frontline health care workers were initially prioritized over LTC residents and staff. It is believed that this hindered the efficiency and effectiveness of Ontario’s vaccine rollout,especially as subsequent vaccine shortages emerged; whilst in Manitoba, concerns had been reported regarding its 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. 
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.
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. The Federal government has more recently announced that Pfizer will deliver one million vaccines per week, every week until May 10th. This is expected to greatly increase the speed and coverage of Canada’s vaccine rollout . Furthermore, it further 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 and that possibly every adult Canadian will be able to have received a first vaccine dose by the end of June 2021. 
Significant Vaccine Hesitancy Exists Amongst LTC Staff in Some Provinces
Furthermore, 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 26.7-96.4% in at least one part of Ontario [54, 55] and less than 74% overall uptake by staff in some settings, especially across New Brunswick, Ontario and Quebec. Numerous reports highlight vaccine hesitancy among staff in LTC settings stemming from concerns about vaccine safety and efficacy [6,21,22]. However, vaccine uptake among British Columbia and Nova Scotia LTC staff has been relatively higher, with 89% and 86% accepting a first dose so far . Low vaccine uptake among LTC staff has been attributed to a number of factors, including employers making staff go off-site to get vaccinated or failing to offer paid leave to get vaccinated . 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. Moreover, the recent concerns over the AstraZeneca vaccine has been cited as contributing to low uptake among staff in some LTC homes . Currently, a number of LTC homes are targeting staff through ‘hallway conversations’, in hopes of having a conversation around why they may be hesitant to vaccinate. Further, a team of researchers from the University of Toronto and McGill are holding nightly drop-in ‘zoom’ sessions for LTC staff to ask questions about getting vaccinated . Two Ontario homes with >90% staff vaccination emphasised communication with staff. Both homes had an internal ‘vaccine ambassador’ who encouraged staff to get a vaccine, while also offering paid time off to employees to attend their vaccine appointments .
Infections, Outbreaks and Deaths in Vaccinated LTC Settings
Discrepancies between provincial jurisdiction vaccine rollouts in LTC settings have led to fragmented vaccination coverage in LTC settings across Canada . 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 an 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 had declined by more than 95% since December . Moreover, the Ontario COVID-19 Science Advisory Roundtable found that eight weeks after LTC vaccinations began, COViD-19 infection was reduced by 89% among residents and 79% among staff, and that COVID-19 related deaths decreased by 96% . Their report also notes that vaccines alone have not been solely 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 workers and LTC staff. The report cites targeted behavioral interventions, information campaigns, and the need for paid leave time for staff as mechanisms to increase vaccine uptake among staff. Overall, the rapidly declining numbers of COVID-19 in Canadian LTC homes support evidence that their early vaccination efforts, in combination with strong infection prevention and control measures, have been 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. As of March 23, the total case count had risen to 20 residents and three staff . On March 9, 2021 an LTC home in Surrey, British Columbia reported 2 COVID-19 infections, one among residents and the other among 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  .
As of March 10, 2021, CHSLD Lionel-Emond in Gatineau had reported more than 60 total cases among staff and residents, resulting in five deaths. At the onset of this outbreak, 96% of the home’s residents had received an initial dose of the COVID-19 vaccine, while only 41% of staff had received an initial dose of the vaccine . Furthermore, it is believed that a full immune response was not yet developed among vaccinated residents and staff, as they had only received one vaccine dose, likely enabling the infection to spread more easily among both residents and staff while adversely affecting them. These examples highlight the potential consequences of extending the second dose timing to four months among older adults. A recently published REact-2 study found that 21 days after one dose of the Pfizer-BioNTech vaccine adults younger than 60 years of age had 80% antibody positivity, but only 48% and 34% positivity amongst those aged 70 and 80 years of age and older, respectively. Further, antibody positivity increased to 94% and 88% in these older adult populations after their second dose was administered . Similarly, another recent study of residents and staff in LTC homes by Canada’s COVID-19 Immunity Task Force found that LTC residents had a much weaker antibody response following a single dose of the Pfizer-BioNTech vaccine than staff . Overall, these findings in combination with these recent outbreaks illustrate why NACI and provincial governments are now beginning to reconsider second dose timing amongst older adults and LTC residents whose second dose has been delayed by 12 to 16 weeks. Furthermore, these examples highlight that vaccine coverage is not a ‘magic bullet’ – and should continue to be paired with strong infection prevention and control measures to protect those living and working in LTC homes.
A Renewed Push to Relax Activity and Visitor Restrictions in LTC Settings
With LTC vaccinations wrapping up, increasing attention is being paid to the quality of life issues that stem from the effects of social isolation and visitor restrictions that have plagued residents of LTC homes over the pandemic . With emerging data showing high vaccine efficacy among older populations, advocates are increasingly calling for ways to support greater uptake of vaccines among LTC staff and vaccinating family caregivers. This would ensure additional protection for residents, which would enable the loosening of restrictions that have caused residents to suffer from extreme isolation over the course of the pandemic. While the United States CDC recently released guidance to ease visitor restrictions in LTC homes, as well as to permit hugging and other forms of close contact between residents and visitors, with the exception of British Columbia, there has been a reluctance to provide similar guidance in Canada thus far. The growing worry about a third wave caused by Variants of Concerns are driving cautious responses to relaxing activity and visitor restrictions, as the possibility of new lockdowns exist. Nevertheless, in the absence of any official provincial/territorial or federal guidance in Canada, a number of LTC homes have begun to start resuming some 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 .
British Columbia also recently announced that beginning April 1st, 2021, it will relax its rules for its 30,000 LTC and retirement home residents. Residents will be allowed to resume group activities and eat meals together in their communal dining rooms, and won’t have to stay two metres apart from one another. The current policy of needing to have a single designated visitor will also no longer apply. Instead,anyone will be able to visit with a resident through a new system that will allow up to two adults and one child at a time to book visits with residents while masked. Visits can occur indoors or outdoors. Indoor visits will no longer require any supervision, and hugging will be allowed. Residents will also be able to take trips outside their nursing homes without having to isolate inside their rooms after returning. BC acknowledged that these loosened restrictions will likely lead to more outbreaks. However, with 95% of its residents and 91% of its staff vaccinated with at least one dose of a COVID-19 vaccine, as well as no evidence that current outbreaks are leading to new deaths, Dr. Bonnie Henry, B.C.’s Provincial Health Officer noted that “We’re at a point where the benefits of having those social connections and interactions outweigh the risks, and we know that we can manage those risks with the vast majority of residents and staff now being protected with immunization,”. Other provinces will likely follow suit and further loosen their COVID-19 protocols for more of these activities in the long-term care sector once almost all of their residents and staff are vaccinated, and Ontario officials have said they are currently considering loosening restrictions as well .
Vaccinating Canadians Beyond LTC Settings
Canada’s provinces and territories have also released strategies focused on priority populations beyond residents and staff of LTC settings – as over 90% 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.
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 The Hamilton Spectator. COVID Vaccinations in Hamilton Retirement Homes. March 3, 2021.https://www.thespec.com/news/hamilton-region/2021/03/23/covid-vaccinations-hamilton-retirement-home.html
 Hamilton. COVID-19 Vaccine Distribution. March 2021. https://www.hamilton.ca/coronavirus/covid-19-vaccine-distributio
 CBC. BC 23 New Cases of COVID-19 identified at LTC Home. March 15, 2021. https://www.cbc.ca/news/canada/british-columbia/23-cases-of-covid-19-identified-in-outbreak-at-kelowna-care-home-where-most-residents-staff-vaccinated-1.5951130
 CBC. Province Pushes Staff to GEt Vaccinated at Gatineau Care Home. March, 2021. https://www.cbc.ca/news/canada/ottawa/chsld-lionel-emond-gatineau-covid19-outbreak-cause-1.5943042
 Pimenta, D., Yates, C., Pagel, C., & Gurdasani, D. (2021). Delaying the second dose of covid-19 vaccines.
 Global News. Gatineau Care Home Coronavirus Outbreak. February 2021. https://globalnews.ca/news/7685720/gatineau-care-home-coronavirus-outbreak-lionel-emond/
. Brockman et al. (2021). Weak humoral immune reactivity among residents of long-term care facilities following one dose of the BNT 162b2 mRNA COVID-19 vaccine.https://www.medrxiv.org/content/10.1101/2021.03.17.21253773v1
 CBC. How these 2 nursing homes bucked the staff vaccination trend. March 26, 2021. https://www.cbc.ca/news/canada/ottawa/ottawa-nursing-home-highest-vaccine-uptake-staff-1.5964362
 British Columbia Ministry of Health. COVID-19 Vaccination Rates in LTC and Assisted Living Facilities. February 2021.http://www.bccdc.ca/Health-Info-Site/PublishingImages/health-info/diseases-conditions/covid-19/data/LTC-vaccine-coverage-by-Facility.pd
 The Globe and Mail. B.C. opens way to social closeness at LTC homes while other provinces review isolation policies. March 26, 2021. https://www.theglobeandmail.com/canada/article-bc-opens-way-to-social-closeness-at-ltc-homes-while-other-provinces/
 Toronto Star. At least 50 Ontario long-term-care homes have a COVID-19 outbreak. How many staff in the homes are vaccinated? The province has no reliable idea. March 27, 2021. https://www.thestar.com/news/investigations/2021/03/27/at-least-45-ontario-long-term-care-homes-have-a-covid-19-outbreak-how-many-staff-in-the-homes-are-vaccinated-the-province-has-no-reliable-idea.html?rf
 NACI. Rapid Response Recommended Use Astrazeneca Vaccine Younger Adults. March 29, 2021. https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/rapid-response-recommended-use-astrazeneca-covid-19-vaccine-younger-adults.html
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: