In this week’s message you will find:

• COVID-19 surveillance and vaccine updates
• Third dose booster eligibility 
• Vaccine mandate and exemptions
• New to Practice webinar
• Changes to isolation requirements
• Diabetes supports expanded to young adults
• Empower Women Award Nominations due Friday

Situation Update

COVID Surveillance Update

Since our last update on Thursday September 9:

• Daily cases up: 366 new cases of COVID-19 have been identified since last Thursday, a daily average of 61 (up from 43 last week). This includes 49 new cases today. The total case count in Manitoba now stands at 59,466.
• Test positivity up: The provincial five-day test positivity rate is 2.9%, up slightly from 2.6%.
• Active cases up: There are 584 active COVID-19 cases province-wide, up from 456 last week.
• Variants of concern: 344, or 59%, of active cases have been identified as a variant of concern. Delta is the dominant variant of concern in Manitoba. 
• Hospitalizations: There are 69 people in Manitoba hospitals due to COVID-19, down from 77. This includes 15 COVID-related patients in Manitoba ICUs, down from 16. 
• Four more people have died from COVID-19 since last Thursday. This brings the total COVID-19 related deaths to 1,203.

According to Health Canada’s tracking, Manitoba had 30 cases per 100,000 over the last seven days, up from from 21 a week ago. Manitoba continues to have the lowest case rate outside of the Atlantic region. Alberta and Saskatchewan continue to lead the provinces with 241 cases per 100,000 in Saskatchewan (up from 217 last week) and 233 in Alberta (up from 199 last week).

Dr. Roussin noted this week that we are now seeing the signs of the beginning of a fourth wave, largely fueled by an increase in cases in the Southern Health Region. The seven day average of new cases in Southern Health has increased to 22.4, compared to just 17.7 in Winnipeg with a much larger population. The emergence of a fourth wave can be identified in the chart below. Southern Health has the lowest vaccine uptake in the province, with 62.9% of individuals age 12 and over fully immunized in Southern compared to 84.0% in Winnipeg.

Vaccination Update

Since our last update on Thursday, September 9:

• 83.9% of Manitobans age 12 and up have received at least one dose, up only slightly from 83.2% a week ago. 
• 78.9% have received two doses, up from 78.1% a week ago.

For current active cases in Manitoba, 30% are fully vaccinated, while 13% are partially vaccinated and 57% are unvaccinated. While breakthrough infections are rare, they will feel overstated as more than two thirds of all Manitobans are fully vaccinated. You can discuss this with your patients using a new Q&A at Man​i​to​baVac​cine​.ca that helps to put these numbers in perspective, and offers reassurance that fully vaccinated people are less likely to get infected or spread COVID-19 to others.

Third Vaccine Doses

Effective immediately, some patients will be eligible for a third dose of COVID-19 through their health care provider. This includes three groups: specific groups considered moderately to severely immuno-compromised; individuals who require a third dose to travel; and individuals who received a vaccine abroad not approved in Canada.

These are not considered booster shots, but rather a third dose to complete the full primary vaccination series for patients who require a third dose. A primary vaccine series is generally considered to be the number of initial doses of vaccine given to induce an immune response and provide initial protection. This is different from a ​“booster” dose, which is used to boost the immune system when protection from a primary vaccine series shows signs of waning over time.
These individuals should be immunized by a health care provider, such as a physician or pharmacist, and not at a provincial super site or pop-up clinic.

• Physicians who do not offer the vaccine in their practice are encouraged to refer to a doctor’s office offering the vaccine. A complete list of the dozens of medical clinics offering the vaccine is maintained at Man​i​to​baVac​cine​.ca.
• Physicians offering the vaccine are reminded to consider their supply needs for their next weekly vaccine order.

Immuno-Compromised Eligibility

The following individuals, who are considered moderately or severely immuno-compromised, are eligible for a third mRNA dose to complete their primary vaccination series. This includes individuals who

• Are receiving active chemotherapy (or immunotherapy) for cancer;
• Have received a solid organ transplant and are currently receiving chemotherapy or other immunosuppressive therapy;
• Were born with moderate or severe dysfunction of their immune system;
• Are living with untreated or advanced HIV-AIDS; or
• Are taking certain medications that severely affect the immune system. 

The following individuals should talk to their doctor about the risks and benefits of an additional dose. This includes individuals who are:

• Receiving hemodialysis or peritoneal dialysis;
• On the list to receive a solid organ transplant; or
• Have a ventricular assist device. 

→ The province’s clinical practice guidelines have been updated with full details about eligibility. You can access the guidelines here, specifically pages 27 to 30. 

The move to offer a third dose is in line with new recommendations issued earlier this week from the National Advisory Council on Immunization. NACI found that the general population develops a robust immune response to the primary vaccine series of two doses of the Pfizer, Moderna or AstraZeneca vaccines, or one dose of the Janssen vaccine. 

Immuno-compromised individuals have a weakened immune system due to disease or treatment. Evidence to date shows that some immuno-compromised individuals have a lower immune response to COVID-19 vaccines compared to the general population. Recent studies show that some individuals who are moderately to severely immuno-compromised who did not respond to or who had a reduced immune response after two doses of an mRNA vaccine can have an increased immune response after a third dose of an mRNA vaccine.

Other Eligibility for Third Dose

Some individuals may require a third dose of COVID-19 vaccine to be eligible to travel. This could include individuals who received a mixed-dose vaccination series. These individuals should go through an informed consent process and can only receive their vaccine from a physician or pharmacist. 

For individuals who received a COVID-19 vaccine that is not approved by Health Canada, they are also eligible for a third dose. Some individuals received doses in other countries, such as Sinovac in China. Because some vaccines aren’t approved by Health Canada, they aren’t recognized for Manitoba’s COVID-19 proof-of-immunization card. With a third dose using an mRNA vaccine, they will be recognized as fully vaccinated. For these individuals, they can receive their dose with a physician, or at a pop-up, mobile or super site clinic. 

Vaccines approved in Canada include Pfizer, Moderna, AstraZeneca and Johnson & Johnson. 

Vaccination Mandate and Exemptions

There are several updates about the vaccination and testing requirement, as well as vaccination requirement exemptions.

Medical Exemptions

Today, the province announced some of the details about who is eligible for a medical exemption from COVID-19 vaccination, and how the process will work to request an exemption. 

Medical exemptions will be considered for the following situations after confirmation by the noted specialist:

• Myocarditis or pericarditis within seven days of an mRNA vaccination, confirmed by a cardiologist
• Guillian-Barré syndrome within 42 days of vaccination, confirmed by a neurologist
• An adverse event following immunization (AEFI) where a provincial medical officer of health has confirmed they recommend against further vaccination
• Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT) confirmed by CCMB hematologist (contraindication for further AstraZeneca vaccination, but specialist will assess suitability of mRNA vaccine)
• CAR‑T therapy or allogenic or autologous stem cell transplant within the last three months, confirmed by CCMB hematologist/​oncologist
• Solid organ transplant recipients, including pre-transplant within two weeks of transplant and post-transplant within the last month regardless of induction therapy, confirmed by the the licensed specialist supervising the transplant
• Active receipt of anti-cancer drug therapy may attenuate the immune response to vaccination, but given the risk posed by COVID-19, vaccination may still be recommended but a deferral may be considered by a CCMB oncologist/​hematologist
• Severe allergy or anaphylactic reaction to a previous dose of a COVID-19 vaccine or any of its components that cannot be mitigated, as assessed and confirmed by an allergist at the HSC Allergy Clinic 

It’s important to note that a severe allergy to a COVID‑19 vaccine or its components is not, in and of itself, a reason for medical exemption. The HSC Allergy Clinic has been able to safely administer the vaccine in micro-doses to those with severe allergies. Allergists will be able to assess individuals and decide if an exemption is needed.

→ See our update last week for more details and how to refer a patient to an allergist. 

The province has a complete list of medical situations that require further consultation before immunization, after which an exemption may be considered. Please see this Public Health memo which outlines the medical exemptions starting on page two. 

Vaccination and Testing Mandate — Physicians and Medical Clinics

There is now more clarity that the provincial vaccination or testing requirement for the public sector will include all physicians as well as staff in doctors’ offices involved in direct patient care.

Shared Health released further details today about the definition of direct care workers. This includes: 

• Physicians, nurses, allied health professionals, support services and others in public and private health care settings. This includes those who may come in direct contact with patients/​residents/​clients, patient/​resident/​client care environments, patient/​resident/​client care equipment and blood and body fluids.
• Direct patient care involves providing hands on or psycho-social care, face-to-face contact with patients for the purpose of diagnosis, treatment. and monitoring. This would not include administrative or support services where there is no direct contact with patients. 
• A patient care environment is defined as any enclosed space where the diagnosis, treatment and monitoring of patients occurs.

In anticipation of the October 31 effective date, Shared Health and RHA health facilities and services will begin collecting vaccination status for employees in the coming days.

The full Shared Health memo is available here.

Further, the College of Physicians and Surgeons of Manitoba has clarified in a recent vaccine FAQ that physicians ​“should be fully immunized against COVID-19 (unless rare medical reasons preclude vaccination) as part of evidence-informed practice of medicine.” They further state that it ​“CPSM’s expectation is that if you are treating patients, then you must also comply with the government and Shared Health rules.”

Regarding staff in medical clinics, CPSM notes that ​“employees or staff who interact directly with the public should be fully immunized or submit to testing and wear the appropriate PPE.”

The full CPSM FAQ is available here.

New to Practice Webinar — October 12

Starting your practice is a major milestone for young physicians, and this milestone has only become more complex during COVID-19. We’re here to help you navigate this transition in your journey as a physician.

We are excited to announce our New to Practice webinar for 2021! This session will cover:

• What Doctors Manitoba offers you
• Benefits and insurance
• Billing: tips and common questions
• Virtual care
• Practicing during the pandemic
• Q&A

Details:

• Tuesday October 12 at 6PM
• Register here
  

Change to Isolation Requirements

Based on evolving evidence and in an effort to ensure positive cases continue to identify their close contacts, Dr. Brent Roussin announced yesterday the province is making changes to the self-isolation requirements for close contacts of COVID positive individuals. 

The required self-isolation or quarantine period for close contacts will change from 14 days to ten days. Testing for asymptomatic contacts will change from day ten to day seven. Manitobans will then be required to self-monitor an additional four days. 

Dr. Roussin noted that a negative test during the period of isolation means there is less than a 1% chance of becoming infectious after the tenth day. In addition to the adjusted isolation time, Manitoba will exempt close contacts from self-isolating if they are asymptomatic and were infected with COVID-19 within the past six months. These changes will be implemented in the next several weeks. 

If you have any questions or need clarification on isolation requirements click here.

Diabetes Supports Expanded to Young Adults

The Manitoba government will now cover the cost of advanced glucose monitors and insulin pumps for individuals who are 25 years old or younger. Currently, insulin pump coverage is only in place for individuals under the age of 18. 

To be eligible for insulin pumps coverage, individuals must be diagnosed with Type 1 diabetes and have an endocrinologist’s recommendation for the use of a pump. Pumps are provided with no deductible or co-payment, covered 100% by the province. The coverage will begin in November. 

Coverage for advanced glucose monitors will also require referral from a specialist. Similar to test strips and other diabetes supplies, advanced glucose monitors will be covered under Pharmacare after the income-based deductible is met. Those receiving Employment and Income Assistance can receive monitors at no cost. Coverage for advanced glucose monitors will begin September 28.

Empower Women 2021 Awards Nomination

The Manitoba Status of Women Secretariat is seeking nominations for the Empower 2021 awards. Originally set for 2020, the pandemic caused the award process to be paused. The Empower Awards have been relaunched and will now recognize exceptional contributions to the pandemic response. The award will given to two deserving Manitoba women, one adult and one youth (age up to 24).

The award recipients will be graded on community involvement, demonstrated need, and intersectionality, along with addressing systemic issues, lasting change, and scale of response. Priority will be given to community led volunteerism. The awards will be presented in a small ceremony, pandemic permitting, on October 22, 2021 during Women’s History Month. Applications are due this Friday, September 17. Learn more about the awards HERE and nominate an outstanding woman HERE.