Royal Alexandra Hospital Foundation

On the evening of Tuesday, April 27th, over 425 people registered to tune in and hear from infectious diseases specialist Dr. Mark Joffe for his keynote Speaking of Health presentation on "The COVID-19 Pandemic: Past, Present & Future."

Given the onset of the third wave of the pandemic and the resulting strain on frontline workers battling the virus, attendees were asked to make a suggested donation of $10. People responded—the event raised $3,335 to directly support the hospital’s frontline staff!

Attendees described the lecture as “extremely informative,” “excellent,” “so thoughtful and well-presented,” and that Dr. Joffe, “provided important information and perspectives in a very clear and accessible manner.”

One attendee even shouted in the chat, “Dr. Joffe, you’re OUR Dr. Fauci!!!”

Several attendees promised to “generously share [the info] with as many people as possible” so without further ado, see below for a full recap of the presentation, along with a PDF of Dr. Joffe’s presentation slides.

And of course, thank you to our sponsor The Robbins Foundation Canada, and all of our generous donors, for making this possible!

CLICK HERE TO VIEW THE PRESENTATION SLIDES

Quick takeaways

• Past pandemics - Influenza pandemics are not uncommon, and happen roughly every 10-40 years. There were three influenza pandemics in the 20^th century (several with racially charged monikers), and H1N1 early in the 21^st...
  
  
• Coronavirus types - Coronaviruses are not new, causing roughly ⅓ of all common colds. There are many strains of Coronavirus, most that only infect animals.. In recent years, three new strains of Coronavirus have emerged, have spread from animals to humans and have caused SARS, MERS and, now, COVID-19.
  
  
• Variants – Mutations are natural, and often cause little change. Some variants are more transmissible and may cause slightly more severe disease. Importantly, we also know that current vaccines will protect us from the impact of the common variants in Canada.
  
  
• Vaccine development – Development was “rapid, but not rushed”. No steps were skipped, and instead the gaps between the steps were removed, with huge amounts of attention and funding being directed toward the effort.
  
  
• Vaccine effectiveness – ALL vaccines are effective. Dr. Joffe urged participants to get any vaccine available to them, and to advise friends and family members to do the same.
  
  
• Vaccine hesitancy and the ‘blood clot issue’ – Blood clots are now recognized as uncommon side-effects of vaccines produced by AstraZeneca and Janssen (Johnson & Johnson), occurring in 1:100,000 – 1:250,000 vaccine recipients. The risk of serious disease, including blood clots, is much higher from COVID-19 than from vaccines used to prevent it.
  
  
• Why so much time between the first dose and second dose? – The initial studies were done using 21-28 days between doses as a way to help get vaccines approved and available as quickly as possible. With the first dose providing 80% protection, when vaccine supply is limited, the idea is to give everyone 80% protection before moving onto administering the second dose.
  
  
• Vaccines for children? – There’s no reason to believe the vaccines won’t be safe or effective for children, but we first need to prove that. Studies are underway and we should have more information very soon. (The Pfizer vaccine has now been approved in children 12 years of age and older and is now being rolled out in Alberta.)
  
  
• Another pandemic? – When asked if we will see another infectious virus that spreads from animals to humans, history and science say ‘yes.’ The question is, how much time and money we will invest in preparing for it…

---

PART 1: THE PAST

History of pandemics

Dr. Joffe opened his lecture by first thanking attendees for joining, thanking the Royal Alexandra Hospital Foundation for the opportunity to speak, and thanking Alberta’s frontline workers, medical staff and conscientious community members for their ongoing work in combating COVID-19.

He then asked if we should be surprised? That is, should we be surprised that we are in the middle of a pandemic?

Dr. Joffe pointed to a March 2020 statement from Former President Trump, quoted as saying, “There’s never been anything like this in history. Nobody knew there would be a pandemic or epidemic of this proportion.”

This, Dr. Joffe pointed out, is blatantly wrong.

History tells us that new strains of influenza emerge every 10 to 40 years, and about eleven pandemics of influenza have occurred since 1580.

Several notable pandemics occurred in the last century:

• The “Spanish Flu” (an H1N1 virus) occurred in 1918-19, and recorded between 20 and 40 million deaths—but was potentially responsible for up to 100 million deaths, considering the accuracy of tracking deaths at the time.
  
  
• The “Asian Flu” of 1957-58 (an H2N2 virus) killed more than two million people worldwide. An Edmonton Journal article from October 30, 1957, mentioned that one quarter of the nurses at the Royal Alexandra Hospital (approximately 200) missed several days of work in relation to the outbreak.
  
  
• The “Hong Kong Flu” (H3N2) killed more than one million people worldwide between 1968-69. It was also noted that the name for this pandemic was particularly racially-charged (which Dr. Joffe addressed later). It became commonplace for people to wear masks at work (as in previous pandemics), not unlike today’s mask mandate.

More recently, the H1N1 pandemic of 2009 brought to light several key issues and implications.

Firstly, there were some communication challenges surrounding the virus’ effect, being described as “Mild in most, severe in some”—a very tough message to convey to the public if the goal is for the virus to be taken seriously. This has also been a challenge during COVID-19.

Secondly, the second wave was considerably larger than the first wave, and it was later realized that deaths from H1N1 were 15 times higher than previously thought (totaling about 284,400 deaths, or 2.8 million years of life lost, globally).

Lastly, it highlighted another sobering reality in our ongoing struggles with influenza viruses:

“The only thing certain about influenza viruses is that nothing is certain.”
- World Health Organization

When SARS (SARS-CoV-1) emerged in 2003, the medical world identified it relatively quickly as a new virus. A new coronavirus, one that had a devastating effect on people’s lungs and respiratory systems.

Coronaviruses account for roughly one third of all common colds, and derive their name from their crown-like appearance under the electron microscope.

Ground zero for the global spread of SARS was traced back to a hotel in Hong Kong. A physician who had been caring for sick patients, had unknowingly been infected with the virus and unintentionally became a super spreader, choosing to cash in on a gift certificate to stay at the hotel instead of staying home. Twelve other tourists staying on the same floor of the hotel became infected and returned to their countries of origin (including Canada).

Within months, 8,500 people had contracted the virus. With a case fatality rate averaging around 10% (17% in Canada), SARS was a very concerning virus.

Thankfully, with some strong public health measures put in place, the world was able to contain the spread and we haven’t seen SARS since.

Scientists believe the disease first spread from bats to the palm civet—a small, cat-sized omnivorous mammal, sometimes called the “toddy cat”—(or perhaps other mammals) and then to humans.

In 2012, a man in Saudi Arabia contracted a disease very similar to SARS, worrying the community that SARS may be back.

The disease was called MERS (full name MERS-CoV, standing for “Middle East Respiratory Syndrome,” a coronavirus).

Thus, a new coronavirus of animal origin was discovered. This strain likely also originates from bats and is able to infect camels and then humans.

MERS continues to circulate but has been mostly confined to Saudi Arabia and the Arabian Peninsula. Approximately 2,500 individuals have had this infection, with a very concerning 34% mortality rate.

The coronavirus family tree, and the novel coronavirus

Coming closer to the present, Dr. Joffe pointed to the first signs of today’s virus, COVID-19, and the family tree of the coronavirus. There are many strains known to infect animals but not humans. There are four strains of the human coronaviruses that are known to cause the common cold, with three new ones identified over the last 20 years (SARS, MERS and now COVID-19).

"On December 31, 2019, the World Health Organization was informed of an outbreak of “pneumonia of unknown cause” detected in Wuhan City, Hubei Province, China – the seventh-largest city in China with 11 million residents.”

Caused by a novel coronavirus, SARS-CoV-2, the disease was officially named as COVID-19 (CO = Corona, V = Virus, D = Disease, and 19 for being discovered in 2019).

In its early stages in China, the virus was noted to cause mild disease in 80% of those infected, more severe disease in 15% with 5% resulting in death or a need for ICU care.Dr Joffe covered the general symptoms of the virus that many of us are now familiar with (coughing, fatigue, headache, chills, nausea, shortness of breath, etc.) as well as its transmission.

At first, there was concern that groceries, doorknobs, and delivered packages might be “fomites” (surfaces, materials, or objects able to carry the infection) and many were focused on disinfecting anything coming into their homes, but this risk was likely over-exaggerated. While the virus can spread by contamination of the hands and then touching of the eyes, nose or mouth (hence the recommendation to frequently sanitize one’s hands, especially given how often one touches their face), transmission via surfaces is rather unlikely. As we now know, the disease is mainly spread via droplets coming from an infected person’s mouth and then being inhaled by a susceptible person.

One of the first outbreaks in North America was in a nursing home in Seattle, WA, which unfortunately foreshadowed the damage the virus would wreak on our elderly populations, and nursing homes in particular.

According to data from Johns Hopkins University, there were ~93,000 cases as of March 3, 2020, then 336,000 cases of COVID-19 on March 22, 2020—a threefold increase in less than three weeks.

The pandemic was officially declared by the World Health Organization on March 11, 2020. The panic started shortly thereafter.

(“For reasons I still don’t understand, the panic lead to a shortage of toilet paper…” said Dr. Joffe.)

It was nearly a year to the day of this Speaking of Health presentation, back on April 23, 2020, when the first wave peaked here in Alberta.

Dr. Joffe shared a stat that 20% of people account for 80% of all secondary infections. These are the “super-spreaders.”

As he described, we still don’t know why some people are super-spreaders and some are not, nor what makes some events superspreading events, and others not.

But where did the virus come from?

Similar to SARS and MERS, the virus is of animal origin and experts say it likely came from bats, but that is hard to say for certain.

However, there’s a cave known in China where the bats have several strains of coronavirus similar to the current one, which makes it seem very, very likely. The WHO considers a leak of virus from a laboratory to be much less likely.

PART 2: THE PRESENT

The virus

One of the most concerning issues of the day is the outbreak in India, with the number of infected individuals escalating rapidly.

Of the ~150 million global cases and over three million global deaths, India has 17.6 million cases and just under 200,000 deaths, compared to Canada’s ~1.2 million cases and 24,000 deaths (as of April 27, 2021). The U.S. has been impacted most by COVID-19 with well over 32 million infections and 570,000 deaths.

Here in Alberta, just under 1% of Albertans with COVID-19 have needed to spend time in the ICU due to COVID, and just over 1% have succumbed to it.

In regard to the latest wave and Albertans affected, Dr. Joffe noted that severe outcomes have been seen at ALL age ranges, and no one is particularly immune to the effects of this virus.

“No one is particularly immune to the effects of this virus.” - Dr. Joffe

The variants

It is natural biology for viruses to change, and the variants for COVID-19 reflect mutations that have led to changes in the surface spike protein, or other components of the virus.

There might be some changes in how quickly or tightly it binds to a cell surface, he said, but most mutations don’t amount to anything, and many mutations can actually weaken the virus.

However, there are some that make it more serious or infectious, or could help it evade our immune systems or our laboratory tests—though there’s been no sign of the latter to date.

Looking at Israel’s situation as an example, the B.1.1.7 variant that emerged from the U.K. was introduced in mid-December 2020 and became the dominant strain over just three and a half weeks. This occurred just as Israel began its national vaccination campaign and it was possible to see that vaccination protected against both the ‘original’ strain and the U.K. variant.

In regard to risk, Dr. Joffe counseled attendees that while the variants are generally more transmissible and in some cases slightly more serious, they are not cause for enormous alarm.

In particular the B.1.1.7 variant (a.k.a. the ‘UK variant’), caused 4.1 deaths per thousand compared to 2.4 deaths per thousand for the non-variant strain, in one study. So, while there is a slight increase in mortality, this is not a large increase.

In other words, it’s not ‘massively more deadly’ than the non-variant strain.

The main reason to not panic is that we know that current vaccines will protect us from the impact of the common variants.

The vaccines

Dr. Joffe referred to another quote from former President Trump in which he stated, “One day, like a miracle, it will disappear.”

Dr. Joffe’s response would be that no, it probably won’t ‘just disappear,’ and it won’t be a miracle.

Or if it is, the vaccines are the miracles.

If a movie were made about the development of the vaccines, it would be titled, “The Absolutely True, Incredibly Amazing Story of the COVID-19 Vaccine”, after the article written by Tara Haelle.

At this time, four companies have developed COVID-19 vaccines that are licensed in Canada: Pfizer, Moderna, Janssen (Johnson & Johnson), and AstraZeneca.

All of the vaccines are highly effective.

Early trials comparing two of the vaccines to placebos, showed over 90% prevention of infection.

Of these four vaccines, Johnson & Johnson and AstraZeneca’s products are similar in leveraging the ‘viral vector’ mechanism, which uses a modified and inactive version of a different virus to provide defense instructions to one’s cells. Pfizer and Moderna’s use mRNA technology, where the vaccine uses mRNA to teach cells how to make a protein (or part of a protein) that signals to our bodies to activate the immune response and pump antibodies out to attack the virus.

AstraZeneca’s blueprint for vaccine development has been around for 50 years, and the technology behind Pfizer and Modern’s has been in development for nearly 30 years. So, these technologies are by no means new.

Dr. Joffe went on to list ten full reasons why and how we were able to get Covid-19 vaccines so quickly without cutting corners, describing the process as “rapid, but not rushed.”

The reasons included the fact that pandemic plans were already in place, China identified the novel coronavirus very quickly, shared this information with the world rapidly and substantial funding was granted immediately. Studies attracted a huge number of volunteers and the trials themselves started right away—yielding rapid results. The clinical trials process was streamlined and accelerated, with regulation taking place while the studies were continuing (removing the usual gaps that often exist within the regulatory and administrative actions needed to license new products). The early vaccines also worked well, which means less time was spent going back to the drawing board and data was collected electronically, which helped to further speed up the process.

“When you have smart, innovative creative people who have access to the funding they need, amazing things can happen.” - Dr. Joffe, referring to the development of the vaccines

Dr. Joffe also addressed the concern around the blood clots that are now linked to the AstraZeneca and Johnson & Johnson vaccines, and vaccine hesitancy in general.

The risk of experiencing blood clots after receiving the AstraZeneca vaccine appears to be 1 in 100,000 - 250,000 people vaccinated.

While this number may seem high enough to be of concern, Dr. Joffe shared some other stats that put it into perspective. The normal risk of experiencing blood clots from taking oral birth control is much higher at about 1 in 2000 (each year), and is 1 per 1000 for people who go on a long-haul flight.

For someone who has COVID, the risk of blood clots is 1 in 10. If you are in the ICU with COVID, it’s 1 in 5.

“The virus itself causes way more blood clotting than a vaccine ever could. I would recommend getting ANY vaccine currently available.” - Dr. Joffe

And the fact that we’ve been able to identify side effects like this so early is actually a good thing. This tells us that our monitoring systems are working at identifying uncommon or rare side effects. The more we know and the sooner we know it, the better we can prevent it in the future.

Much of the vaccine hesitancy is likely due to general lack of information—or misinformation—but the facts are clear that the vaccines are highly effective.

Citing above stats around the efficacy of the various vaccines, Dr. Joffe once again urged participants to get any vaccine available to them, and to advise friends and family members to do the same.

Measuring COVID’s impact using ‘excess mortality’

To better understand the true toll of the pandemic, Dr. Joffe explained ‘excess mortality’ and how it’s changed for various countries due to COVID-19.

The majority of countries track their annual mortality rates (how many people die per year), and the rates are surprisingly stable from year to year.

Looking at ‘excess mortality’, or the overall change in deaths per year, can tell us how hard we’ve been hit by the virus, as any extra deaths are likely due to COVID-19, whether directly or indirectly.

In Canada in 2020, compared to an average from 2015-2019, there was a 3% increase in mortality, equaling 9,100 deaths. The US was worse off, with their excess deaths being 14% higher, or 420,000 excess deaths in 2020 compared to the average over the four previous years.

Australia and New Zealand actually recorded fewer deaths compared to previous years. Dr. Joffe mused that this was likely due to the island nations’ abilities to dodge the brunt of COVID landing, and that the COVID-related restrictions essentially eradicated their flu season. Also, lockdown measures may have led to a decrease in typical accidental deaths such as motor vehicle deaths.

PART 3: THE FUTURE

The many waves of COVID

Looking toward the future, Dr. Joffe outlined the ‘four predictable waves of COVID.’

The first wave is the immediate impact of the virus, and all direct disease and deaths.

The second wave reflects delayed presentation of urgent conditions. That is, issues like heart conditions that may not be addressed in the thick of the battle against COVID, either because individuals avoid seeking care or, in some jurisdictions, where healthcare services may not have been available.

The third wave represents the chronic diseases, like diabetes or chronic lung diseases, that may have been ignored or under-treated that and that can bring with them long-term impacts.

The fourth wave is the impact of psychological trauma we’ve all endured through personal losses, months and months of restrictions and isolation, resulting in psychological trauma and mental health issues.

Dr. Joffe also added a fifth wave to the mix. Some individuals who experienced COVID could have prolonged and protracted symptoms of COVID, called “long COVID.” Currently, it is difficult to say how common this will be and how long the effects will last. Time will tell.

The societal implications of disasters

What have we learned from this that will make us better?

With disasters, Dr. Joffe explained, we can either learn and innovate, or fail to learn, and regress as a result.

Dr. Joffe introduced the term “syndemic,” coined by M. Singer in the 1990s. What it refers to is the combination of biological events (like a virus) and social interactions. In this synergistic interaction of biology and society, or syndemic, he said, it is clear that some segments of society have been impacted far more than others. Think of those whose jobs do not allow them to limit exposure to the virus, those who have pre-existing conditions, those who have more crowded, multigenerational housing, and generally those whose circumstances or socio-economic status impact their ability to social distance effectively.

Calling back to the name of the “Hong Kong Flu,” we have again seen blatant racism rise to the surface, with too many examples to name.

There is also an “infodemic” of false and misleading information, which is often dangerous.

Can we fund both our hospitals and our economy? Too often in this pandemic, we’ve been asked to choose. We need to develop better strategies to be able to support both effectively in the future.

To what degree will countries and governments be allowed to implement public health restrictions in the future? We will likely need a Supreme Court case in Canada to provide guidance on the matter.

Vaccine passports? There will be lots of discussion around this topic, and whether one will have to show proof of being vaccinated before attending a large sporting event or getting on a plane.

Is the handshake dead? Hard to say, but again, time will tell.

Will we see another infectious virus that spreads from animals to humans (“zoonotic diseases”)? Yes, absolutely, Dr. Joffe said.

The question is, how much time and money will we invest in preparing for it.

“The best preparation for tomorrow is to do today’s work superbly well.” - Sir William Osler

Dr. Joffe also prompted the audience, how will we relate to each other in the future? Are we a global community? Has it sunk in that the health of one community can very easily impact the health of another community?

Q&A

Following Dr. Joffe’s info-packed lecture, participants were eager to pick his brain even further. Questions and answers below have been paraphrased and condensed for the sake of brevity and clarity.

What is your opinion of using a different vaccine brand (of same or different variety) for the first dose and the second dose?

• The current recommendation is that if you get vaccine A, your second dose should be vaccine A, and not vaccine B. However, there is work underway to see if the ‘mix and match’ method is safe and effective. It could even prove to be better, but we do not know this yet.

Why is there four months between the first dose of the vaccine and the second dose?

• The reason for the dosing schedule is to get as many people their first shot of the vaccine as possible. After the first shot, recipients are about 80% protected, and the second takes it up into the 90s. The initial studies were done in a way to help get vaccines approved and available as quickly as possible. Thus, second doses were provided 21-28 days after the first and this became the official ‘recommendation.’ However, it does not mean that this is the best or most effective strategy.
• What we know from other vaccines is that they often work better if there is a slightly longer gap between the initial shot (the “prime dose”) and the second shot (the “booster dose”).
• Our National Advisory Committee on Immunization (NACI) has conducted modelling studies showing that, overall, when vaccine supply is limited it is better to get most of the population their first dose of vaccine, rather than giving two doses to a smaller group. So, the idea is to give everyone 80% protection before moving onto administering the second dose.

Will influenza re-emerge next year or once we loosen our restrictions?

• It was astounding this year that we had no influenza. Everyone who got admitted to hospital for COVID had their specimens looked at for influenza, meaning we actually looked hard and tested more for the flu than ever, and found NONE. It’s really quite fascinating.
• We always watch Australia and New Zealand because their flu season always come before ours. They did not have one, and lo and behold, neither did we. Why? Is it because COVID outcompetes the influenza virus? This could be part of the explanation, but more likely it is that we followed careful measures to protect ourselves from not getting COVID-19 (wearing masks, staying home when sick, physical distancing, cleaning our hands). I think all those measures together prevented our flu season.
• As to the flu re-emerging, will people with a runny nose or scratchy throat wear a mask when they go out in public in the future to prevent spread of infection? It’s quite common in other countries but not ours. We’ll see.

Once someone is fully vaccinated, can they still carry and pass the virus to someone else?

• We don’t have a full answer to this question yet. There is information gradually coming out that if you are vaccinated and acquire the virus, you have LESS of it then therefore have LESS to spread, but that research is still ongoing. Real world studies in countries that have done well vaccinating their population show marked reduction in infections, hospitalizations and deaths. Vaccines really do work!

When will there be a vaccine for children?

• There’s no reason to believe the vaccines won’t be safe or effective for children. But we do need to prove that. Studies are easier to conduct using people whose symptoms are more obvious (often older people). Of course, these are also the people most at risk for serious COVID-19 and we needed to know whether vaccine could prevent this. Studies in children are underway and we should have information very soon. (The COVID-19 vaccine from Pfizer has been approved in children 12 and over and is now offered in Alberta to everyone 12 and older.)

Besides the obvious steps of getting vaccinated and obeying measures, what else can we do to show support to our healthcare providers?

• Limit the size of your social bubble. Cut back on the number of people you interact with, and tell others to do the same. It’s tough, but it would help. We probably all know grandparents who have not seen their grandchildren and families who have not been able to interact. However, we really need to buckle down, take measures seriously for a little longer and get vaccinated. Things will get better.
• What worries me is the healthcare providers who have been going through this for over a year who are seeing our younger population go out partying and catching COVID. It may be mild but they pass it to a parent or grandparent who ends up in the ICU. And so, our healthcare workers are getting burned out and are flat out exhausted.
  
  

Dr. Joffe closed out the evening by once again thanking frontline workers and medical staff, saying “It’s these brave people who come to work every day to do what needs to be done, to look after Albertans and take care of people.”

One attendee later wrote in to say:

I want to express my appreciation for the excellent ‘Speaking of Health’ lecture you gave on Tuesday night. You provided important information and perspectives in a very clear and accessible manner.

On a personal note I invited my mother to virtually attend the lecture with me. Many years ago she was a nurse at the RAH and your talk brought back many memories for her and some of the pandemics she had worked through. Your sincere comments about the value and impact of health care staff made her feel appreciated and recognized even though it has been decades since she provided her service.

Thank you for making my Mom feel special.

True to form, when Dr. Joffe was offered an honorarium as thanks by Sharlene Rutherford, President and CEO of the Royal Alexandra Hospital Foundation, he kindly chose to instead donate it back to the foundation.

Please join us in thanking Dr. Joffe for sharing his time and expertise, and educating us all on an extremely important topic!

---

About Dr. Joffe

Dr. Joffe currently holds many high-level positions throughout the province in his roles as Vice President with Alberta Health Services; Medical Director for Cancer Care Alberta, Clinical Support Services and Provincial Clinical Excellence; and also as an educator, as Professor of Medicine at the University of Alberta.

He has represented local and national medical communities by serving as President of the Royal Alexandra Hospital Medical Staff Society, two terms as President of the Capital Region Medical Staff Association and two years as President of the Association of Medical Microbiology and Infectious Diseases Canada. He served as Senior Medical Director for Infection Prevention and Control for Alberta Health Services from 2009 through 2017.

Dr. Joffe's major interests are in quality and safety in healthcare delivery and the prevention of infectious diseases in both patients and healthcare workers.

---

Thank you again to our sponsor, The Robbins Foundation Canada, and to all our donors for making this possible. We look forward to welcoming you to future Speaking of Health lectures.

If you would like to see more lectures like this one, please consider making a donation to our Foundation.