We are following up with a special message today about third doses. Since the provincial government announcement yesterday, we have heard from many physicians and members of the public with questions and concerns, particularly about third doses for travel. 

What was announced yesterday?

Yesterday, the government announced three different groups are now eligible for a third COVID-19 vaccine dose. This includes individuals considered moderately or severely immuno-compromised, individuals who require a third dose to travel, and individuals who received a vaccine overseas that is not approved by Health Canada.

→ You can see our summary of the announcement here.
→ You can see the full eligibility at Man​i​to​baVac​cine​.ca

Who is eligible for a third dose for travel?

The government’s announcement yesterday simplified the eligibility for the public and this appears to have created some confusion.
The provincial clinical practice guidelines are clear that individuals can qualify for a third vaccine dose for travel if:

• They had a mixed COVID-19 vaccine series for their first shot (e.g. AstraZeneca then Pfizer, Pfizer then Moderna, etc.); AND
• They have specific travel plans to a country that requires people to be fully immunized with two doses of the same vaccine.

At this point, there does not appear to be a clear resource that lists vaccine entry requirements by country. Public Health has reported to us that this varies by country. For example:

• The UK does not recognize mixed doses
• France, Germany and several other countries do recognize mixed doses
• The U.S. has no vaccine requirements for travel, which means third doses aren’t generally required. 

Some patients may have specific plans within their destination that requires same-dose vaccination, such as a cruise. 

The province’s clinical practice guidelines make it clear that ​“There is no clinical recommendation that individuals who received a mixed schedule should receive an additional dose. However, in recognition that there may be broader considerations at play beyond the effectiveness of the vaccine series, the province of Manitoba is permissive of physicians providing this dose” (see page 30 of the clinical practice guidelines).

Who is NOT eligible for a third dose for travel?

Individuals are likely not eligible for a third dose for travel if:

• Their first two doses were the same (“homologous”, like Pfizer-Pfizer, Moderna-Moderna, or AstraZeneca-AstraZeneca). 
• They have no concrete travel plans.
• They are traveling to a destination that does not require same-dose vaccination to entry (e.g. U.S., France). 

What is a physician’s role in authorizing a third dose for travel?

Individuals can only get a third dose for travel purposes from a physician, or from another health care provider (e.g. pharmacist) if they have a prescription from a physician. This raises the question of what physician’s obligations are for third doses for travel. 

Based on Dr. Joss Reimer’s public comments and the province’s clinical practice guidelines, physicians should ensure a robust informed consent process that clearly communicates both what is known and unknown about the risks and benefits of receiving an additional dose (including the off-label status). This likely includes:

• Reviewing the risks that come with a dose of the vaccine with the patient.
• Advising the patient there is ​“no clinical recommendation that individuals who received a mixed schedule should receive an additional dose.”
• Discussing the broader benefits, such as the benefits to a patient’s mental health or emotional well-being that can come with travel. 
• Ensuring it has been at least 28 days since the second dose was administered.

For physicians getting requests for a prescription from a pharmacy or pharmacist, we are seeking confirmation about whether a visit is required to assess the patient and complete the informed consent process. We have raised this issue with CPSM, and we will report back once we hear more. For the time being, we recommend that physicians conduct an in-person or virtual visit before authorizing a prescription to establish informed consent, and document this clearly. 

Who is billed for travel-related third dose vaccine advice or injections?

Normally, travel related vaccinations (e.g. Twinrix) are not covered by Manitoba Health, so patients are billed directly for the visit and injection. However, because the government advised patients that a mixed dose series was acceptable, we understand they are considering covering the cost of the visit and/​or injection, but a decision has not yet been made. We are seeking an answer on this and we will update you as soon as we have a clear answer.
If patients are contacting you for travel-related third doses, your staff can screen them to confirm they would be eligible. If they are eligible, we recommend waiting to conduct the visit and administer the vaccine until we get clear direction from the province on who should be billed. If the patient is traveling imminently (e.g. requires the shot two weeks before traveling), it may be prudent to collect and hold payment information.

What is the criteria for immuno-compromised?

Not everyone who is immuno-compromised is eligible. Following the NACI guidelines, Manitoba has established very specific criteria for those considered moderately to severely immuno-compromised for whom a third dose may be required. 

• A public friendly list is found at Man​i​to​baVac​cine​.ca under eligibility.
• The full list of medical conditions or treatments is available for physicians on pages 28 – 29 of the province’s clinical practice guidelines.

Third doses are not offered to immuno-compromised individuals at super sites/pop-ups. Patients have to see a physician or pharmacist to get this shot. 

What about 3^rd doses for those who received overseas vaccinations?

If someone received a dose of a non-Health Canada approved vaccine overseas (e.g. Sinovax, Sputnik), they can get one shot of Manitoba-approved vaccine and then be considered fully vaccinated. These individuals can get their third dose from a physician, pharmacist or a super site clinic. 

What about billing visits and injections for immuno-compromised or overseas vaccinations?

The existing tariffs and billing advice in place for first and second doses also applies to third doses for these two groups. You can review our billing guide here. In many of these situations, a visit may be appropriate to accompany the claim for the injection if you:

• Assess more complex medication situations to advise a patient on risks and benefits, or
• Discuss indications and contraindications, or
• Answer a patient’s detailed questions about the vaccine and their personal suitability.

Where a visit is claimed in addition to the vaccine injection, the reason should be clearly documented in the patient chart.

Concerns about third doses and eligibility

We’ve heard from a few members concerned about third doses.

Some have been anxious about the idea of offering a booster shot, or third dose, in Canada when so many lower-income countries are still still struggling to administer first doses. 

The issue of vaccine equity is serious. According to the World Health Organization, only 3% of people in low income countries have received at least one dose of a COVID-19 vaccine, compared to 60% of people in high income countries. They have issued pleas to hold off offering booster shots until low income countries can make more progress. Leaving low income countries largely unvaccinated is both a global equity issue and a local risk, leaving the potential for new variants of concern to emerge that could evade the vaccines. 

So far, Manitoba’s approach is very targeted, using doses primarily for immuno-compromised individuals who do not yet have full immunity against COVID-19. These are not considered booster doses, but third doses to complete the vaccination series. 

Physicians concerned about vaccine equity are encouraged to support UNICEF’s #GiveAVax campaign, which will be matched by the Government of Canada. A gift of $100 will vaccinate approximately 20 people. Learn more and donate now.

We’ve also heard from a few members concerned about protecting health care workers in critical parts of the system that are vulnerable to a fourth wave surge in admissions, such as critical care. We have already raised this issue with provincial officials. While the clinical evidence to support this move is apparently not definitive, the operational vulnerability of our ICUs and other areas could not be any clearer. We will continue to pursue this issue and keep you updated.