Keywords

Introduction

In January 2020, the World Health Organization declared the spread of COVID-19 to be a Public Health Emergency of International Concern (PHEIC). A PHEIC is defined as: “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response” (World Health Organization, 2005, p. 9). A PHEIC declaration is the highest alert level by the WHO and carries with it legally binding requirements for countries in following International Health Regulations (e.g., resource mobilization, data sharing). COVID-19 has caused over 600 million cases and over 6 million deaths worldwide, and more than 4 million cases and over 43,000 deaths in Canada, as of August 2022 (IPAC Canada, 2022; World Health Organization, 2022).

From a public audience perspective, the two most important factors in controlling a PHEIC event are: (1) good risk communication for actionable protective behaviors; and (2) once available, distribution of effective vaccine(s) to protect against severe illness or death. Since the WHO characterized COVID-19 as a PHEIC event, there has been considerable international scientific collaboration and state level funding to sequence the SARS-CoV-2 virus with the aim to develop effective vaccines. Canada, like many other governments, invested substantially through contractual agreements to purchase vaccines from pharmaceutical companies even without knowing which vaccines may successfully pass through clinical trials and regulatory authorizations. This type of investment was critical to reduce the length of time typically required for the development of a new vaccine (i.e., from 10–15 years to about 10–15 months). Canada also made commitments to COVAX (World Health Organization, 2021), a WHO initiative aimed at providing global equitable access to COVID-19 vaccines to low and middle income countries that might not otherwise have the resources to protect their citizens. It has been widely acknowledged that safe and effective vaccines as well as a global mass immunization program are necessary to end the COVID-19 pandemic (The Lancet Microbe, 2021). However, given anticipated scarcity in the availability of safe and effective vaccines, state actors were cognizant that prioritization decisions would need to be made, and that these decisions would need to be created in an ethical, equitable, and transparent manner.

In this chapter, we explore aspects related to the risk governance of public health emergencies, including vaccines, in Canada, with a particular focus on addressing issues of equity and fairness under conditions of scarcity. We will describe how public health emergencies are regulated and managed, including the mechanisms used to establish preliminary recommendations for COVID-19 vaccine priority groups, and public and stakeholder engagement mechanisms. We will then document how some provinces made operational decisions on vaccine delivery within their jurisdiction. We will examine specific opportunities and challenges when the public is engaged in evaluating prioritization recommendations, particularly when those who are consulted may not necessarily reflect the population diversity underlying equity considerations. In order to explore these tensions, we share public comments about COVID-19 vaccine priority groups from age-stratified (18–34 years; 35–54 years; 55 years and older) mixed-gender focus groups in Vancouver, Winnipeg, Toronto, and Ottawa, conducted in December 2020.

Background: Regulating and Managing Public Health Emergencies

In Canada, both Health Canada and the Public Health Agency of Canada play important roles in protecting the health of Canadians. Health Canada is the regulator for any new health product (e.g., vaccine, drug, health technology/therapy) as well as being responsible for federal policy and financial contributions to the healthcare system, among other areas. The Public Health Agency of Canada (PHAC) was created following Canada’s experiences with SARS (Severe Acute Respiratory Syndrome) in 2003, in order to have a stronger and more coordinated public health presence (Canada, 2003). It is through PHAC that some of Canada’s obligations under the WHO International Health Regulations (e.g., surveillance) are met. In order to provide guidance on the use of vaccines approved in Canada, PHAC delegates this mandate to the National Advisory Committee on Immunization (NACI). NACI provides expert advice in vaccine recommendations by evaluating published literature, conducting reviews, and publishing statements and updates.

National immunization recommendations in Canada rely on a long-standing framework that focuses on traditional scientific (e.g., disease burden) and programmatic (e.g., feasibility, acceptability, ethics, costs) factors important for decision-makers (provinces/territories) (Erickson et al., 2005). Since the establishment of NACI in 1964, it has often focused on the scientific considerations in developing recommendations, and the consideration of programmatic factors was mainly done separately by a federal/provincial/territorial committee. This was changed in 2019 when NACI’s mandate was officially expanded to evaluate programmatic factors (Ismail et al., 2020). Consequently, NACI sought to develop a systematic and transparent way of applying an Ethics, Equity, Feasibility, and Accessibility Framework (EEFA). This involved an extensive review of evidence on these aspects as they applied to vaccines, and surveys and consultations with experts and stakeholder groups. Consultations involved key informant interviews with representatives from organizations within Canada (e.g., Public Health Ethics Consultative Group, Canadian Task Force on Preventive Health Care), including representation from Indigenous Nations (e.g., Inuit Tapirit Kanatami, First Nations Information Governance Centre, Métis National Council), and outside Canada (e.g., Strategic Advisory Group of Experts World Health Organization). The full process and considerations are well documented by Ismail and colleagues (2020). Nonetheless, while NACI might make recommendations for immunization programs, it is the provincial and territorial governments that ultimately decide how to implement publicly funded immunization programs.

The COVID-19 pandemic has deepened health inequities in Canada, as some groups—particularly racial minorities and people living in poverty—have been more deeply affected (Public Health Agency of Canada, 2021). At the onset of COVID-19, NACI had the mandate within PHAC to create a set of priority vaccination groups in Canada even before Canada had any knowledge of when and which vaccines would become available, as will be described in the next section. This mandate is based in the need for fair and equitable vaccine distribution.

Creation of Priority Vaccination Groups in Canada

Canada approved the use of two COVID-19 vaccines in December 2020, Pfizer-BioNTech and Moderna, and in February and March 2021, respectively, AstraZeneca and Janssen COVID-19 vaccines were approved. With these emergency authorizations, and given the limited supply of vaccines, provinces and territories had to develop vaccine distribution plans and create priority groups who would have early access to the vaccine, making appropriate modifications as more vaccine supply became available. Based on the EEFA Framework (Ismail et al., 2020), NACI recommended the prioritization of four key populations for early access to the COVID-19 vaccine: (a) those at high risk of severe illness and death from COVID-19, including advanced age; (b) those most likely to transmit COVID-19 to high risk groups, and workers essential to maintaining the COVID-19 response, including healthcare workers, personal care workers, and caregivers providing care in long-term care facilities; (c) workers providing essential services for the functioning of society; and (d) people whose living or working conditions put them at high risk of infection and where infection could have disproportionate consequences, including Indigenous communities (ibid.).

A key component of the EEFA framework was public consultation (Ismail et al., 2020). NACI referred to an expert stakeholder survey conducted in Canada in July and August 2020 (Zhao et al., 2020), and time-series cross sectional surveys with the general population to gauge their attitudes toward the COVID-19 vaccine and group priority (Impact Canada, 2021). The surveys were conducted by Canada’s COVID-19 Snapshot Monitoring Study (COSMO Canada) and are part of an ongoing study which has so far included 11 surveys between April 2020 and February 2021. NACI drew on the results of surveys 6 and 7, the most recent at the time (National Advisory Committee on Immunization, 2020).

The expert stakeholders consulted included members of clinical or public health expert groups involved with PHAC, patient or community advocacy representatives and/or experts from the CanCOVID network,Footnote 1 members of Canadian health professional associations, members of provincial and territorial committees and/or national Indigenous groups, and representatives of federal government departments (Zhao et al., 2020). Stakeholders generally ranked the strategies in the following order from most to least important:

  1. 1.

    Protect those who are most vulnerable to severe illness and death from COVID-19.

  2. 2.

    Protect healthcare capacity.

  3. 3.

    Minimize transmission of COVID-19.

  4. 4.

    Protect critical infrastructure.

The general population survey (Impact Canada, 2021), in which 2000 Canadians participated, revealed that the most commonly identified populations for priority immunization included: those with underlying medical conditions (57%); the elderly (53%); healthcare workers (22%); and frontline/essential workers (18%). However, when asked to rank a pre-determined list of groups to be prioritized to receive a COVID-19 vaccine before others in wave 7 of the survey, a different set of preferences emerged. The most commonly identified group for priority immunization was healthcare workers (40%), followed by individuals with high-risk medical conditions (19%), frontline workers (16%), seniors (12%), long-term care/nursing homes (10%), and children (2%) (ibid.).

Provincial Implementation of Priority Group Recommendations

All provinces and territories devised immunization plans in order to distribute the COVID-19 vaccine in phases, given that insufficient supply required vaccinating some people first while others had to wait. Phase 1 of the vaccine rollout began, for most provinces, between late December 2020 and early January 2021. In all cases, priority groups included frontline healthcare workers, staff and residents at long-term care facilities, and individuals over 80 years of age. Prioritizing these groups is in line with the recommendations developed by NACI explained above; however, definitions of frontline healthcare workers varied across provinces and territories. For example, in Alberta, Phase 1 included healthcare workers in intensive care units, respiratory therapists, and staff in long-term care and assisted living facilities (Alberta, 2021); meanwhile, in Saskatchewan, the category of healthcare workers was broader and included those working in ICUs, emergency departments, COVID-19 units and testing centres, respiratory therapists, code blue and trauma teams, and emergency medical services (Saskatchewan, 2021).

Indigenous populations (First Nations, Métis, and Inuit) were also included as a priority group in most provinces and territories, following NACI recommendations. Indigenous populations in Canada have been deeply affected by the COVID-19 pandemic, and they are particularly vulnerable to health risks due to “reduced access to adequate health care, healthy food and clean water, while also experiencing much greater levels of overcrowded housing, homelessness and incarceration” (Mosby & Swidrovich, 2021, p. E381).

Initial priority categories were expanded as vaccine availability increased, progressively broadening to include other “at risk” categories and the general population. Several provinces reserved the AstraZeneca vaccine for populations between 55 and 65 years of age after NACI revised its guidelines on March 29th due to reports of adverse reactions to the vaccine around the world. Reports emerged of people who had received the vaccine developing blood clots (Dangerfield, 2021; Reuters, 2021), an extremely rare side-effect (Rabson, 2021) that received much media attention. However, due to lack of demand for the AstraZeneca vaccine among the target population, NACI backtracked its decision and on April 16th once again recommended the vaccine for everyone over the age of 18 (Chung & Hogan, 2021). Below, we discuss the initial priority groups in three provinces (Ontario, Manitoba, and British Columbia) that represent the COVID-19 vaccine program context of our focus group participant perspectives reported later in the chapter.

Ontario

In Ontario, the COVID-19 vaccination program started in late December 2020. The province devised a three-phased plan, starting with those deemed at “greatest risk of severe illness and those who care for them” (Ontario, 2021b). The plan sought to prioritize the elderly, those at higher risk due to underlying health conditions, those who live in crowded conditions, those who live in “hot spots,” defined as areas with higher rates of death, hospitalization, and transmission, and those who cannot work from home (ibid.). The province based its immunization plans on available scientific evidence that vaccinating the elderly and those in high-risk situations could prevent severe cases of the novel coronavirus and hospitalizations (Ontario, 2021a). Ontario also followed ethical frameworks and NACI’s recommendations to ensure its vaccination plan was “equitable and fair” (ibid.).

Phase 1 began in late December 2020 and lasted until the end of March 2021. It targeted high-risk populations, including staff, essential caregivers, and residents in long-term care and retirement homes, First Nations elder care homes, healthcare workers identified as highest priority, followed by very high priority, based on the Ministry of Health’s guidance, IndigenousFootnote 2 adults in northern remote and higher risk communities (on-reserve and urban), and adults ages 80 and older (Ontario, 2021b).

Phase 2 of the vaccination plan started in April, coinciding with the third wave of infection and amid strong criticism over the slow pace of the vaccination effort. This phase targeted, in 5-year decreasing intervals, adults aged 79 to 60, those in high-risk congregate settings (such as shelters, community living), individuals with high-risk chronic conditions and their caregivers, and those who cannot work from home (Ontario, 2021b). The third wave of COVID-19, however, quickly tested Ontario’s healthcare system, as the number of new daily cases, new ICU admissions, and deaths climbed steadily. With pediatric hospitals making room for adult critical patients across the province, the vaccination plan was expanded ahead of schedule to include individuals over 50 years of age in “hot spots.” Despite vaccine availability, many in the 55 and over age group rejected the AstraZeneca vaccine, thought to be due to media reports of clotting disorders (Laucius, 2021). Strong criticism and popular demand to offer the vaccine to younger populations led the government of Ontario to offer the vaccine to individuals over 40 years of age by April 19, months before populations under 60 were set to be vaccinated under phase 3 (July 2021 onward). The government was also criticized for offering the vaccine to the general population over 40 while younger educators and those with underlying health conditions remained unvaccinated (Taylor, 2021). The designation of “hot spots”Footnote 3 also generated controversy as some of those areas did not meet the requirements and some argued they had been included in the priority list due to political motivations (Payne, 2021).

Manitoba

Manitoba began vaccinating against COVID-19 in December 2020. The province announced that “every eligible person in Manitoba who wants to be immunized can get the COVID-19 vaccine”; however, “people who are most at risk will get the vaccine first” (Manitoba, 2021). The province announced that while it considered the guidelines provided by NACI regarding priority groups, it would adapt them to the particular context of the province and with the medical advice of local experts (ibid.).

The first phase of vaccination in Manitoba went from December 2020 to February 2021, and it was focused on individuals working in acute care facilities, COVID-19 immunization clinics and testing sites, COVID-19 isolation facilities, prisons, congregate living facilities, and personal care homes. Also included were paramedics, acute care workers, and home care workers born before 1975 (Manitoba, 2021). In March, vaccination was expanded to include other healthcare workers and essential workers, as well as Manitobans over the age of 80. This coverage progressively expanded and by April 21st Manitobans over the age of 50 and First Nations over the age of 30 were eligible to receive a COVID-19 vaccine.

Prioritizing Indigenous populations—defined as First Nation, Inuit, and Métis Citizens (Government of Canada, 2009)—was one of the recommendations outlined by NACI, and it has been adopted consistently across Canada, except for the province of Manitoba. In Manitoba, only First Nations were considered a priority group, while Inuit and Métis Citizens were considered “general population” Manitobans (Manitoba, 2021). This unequal treatment of Indigenous populations was heavily criticized by Métis and Inuit leaders (Robertson, 2021), particularly because Manitoba has the largest Métis population in the country and is considered the homeland of the Red River Métis Nation. The provincial government used the province’s large Indigenous population as an argument to persuade the federal government to increase the province’s vaccine quota (Robertson, 2020). The federal government agreed to increase the vaccine quota to account for First Nations on reserve, who are protected by federal law, but not for any First Nations, Inuit or Métis citizens living in cities. Nevertheless, the federal government asked provinces and territories to provide equitable access to those Indigenous Citizens in their jurisdiction (Robertson, 2021). Manitoba, however, did not amend at that time its priority groups to include Métis and Inuit populations (MacLean, 2021a).

The Manitoba Métis Federation (MMF) denounced the unequal treatment (Wong, 2021). In April 2021, the MMF demanded a public inquiry into the province’s vaccination program and why the Métis People had not been prioritized (Stranger, 2021). To meet the needs of its Citizens, the MMF partnered with a private laboratory to conduct COVID-19 testing for Métis Citizens (Frew & Petz, 2021) and applied for access for vaccine delivery through its Métis-owned pharmacy in order to focus those doses on Métis Citizens (Frew, 2021). In addition to this, some First Nations Chiefs differentially supported Métis inclusion. Some called for the Métis Federation to demonstrate an evidence-basedFootnote 4 need to be prioritized for vaccines (Sinclair, 2021), a position upheld by provincial medical leads (Stranger, 2021), whereas others donated surplus vaccine supplies that could not be used within their own reserve community (Frew, 2021) before vials expired. On May 3, 2021, Manitoba changed its prioritization with respect to Indigenous Peoples to include all Indigenous Peoples—First Nations, Inuit and Métis—ages 18 and up to receive a Pfizer or Moderna COVID-19 vaccineFootnote 5 in acknowledgment of the impacts of colonization on all Indigenous Peoples (MacLean, 2021b).

British Columbia

British Columbia also began vaccinating against COVID-19 in December 2020. The province’s phased vaccination plan, including the creation of priority groups, followed NACI guidance as well as that of the B.C. Immunization Committee and the public health leadership committee (British Columbia, 2021). Phase 1 of the immunization plan was put into action between December 2020 and February 2021, focusing on residents and staff of long-term care facilities, individuals assessed for and awaiting long-term care, residents and staff of assisted living residences, essential visitors to long-term care facilities and assisted living residences, hospital healthcare workers who may provide care for COVID-19 patients in ICUs, emergency departments, paramedics, medical units, and surgical units. Remote and isolated Indigenous communities were also included in this first phase of vaccination (ibid.).

In February 2021, B.C. opened public health immunization clinics to immunize senior citizens born in 1941 or earlier, as well as Indigenous Peoples (First Nations, Métis and Inuit) born in 1956 or earlier, Elders and additional Indigenous communities (British Columbia, 2021). Also included in this second phase were hospital staff, community general practitioners and medical specialists, vulnerable populations living and working in congregated settings, and staff in community homes.

Phase 3 began in April, initially opening up eligibility for the COVID-19 vaccine to British Columbians aged 69–79, Indigenous peoples aged 18 to 64, and people between 16 and 74 who are clinically extremely vulnerable. However, by mid-April, all British Columbians over the age of 40 were made eligible to be immunized (British Columbia, 2021).

Focus Groups

Our research team conducted 12 mixed-gender focus groups with 82 Canadians in Vancouver, Winnipeg, Ottawa, and Toronto between December 8–22, 2020. Participants were recruited using a market research firm (Prairie Research Associates, PRA) using a variety of methods (e.g., emails to individuals signed up as part of existing panels, random digit dialing, ads posted on Facebook). Participants were age-segregated into one of three groups (18–34 years, 35–54 years, 55+ years) for each city, where at least 2 people were recruited in smaller age groupings within each category. For example, in the 18–34 age group recruitment, the market research firm needed to identify individuals between 18–24, 25–30, and 31–34 to ensure a better cross-section of participants. Focus groups were fairly diverse; 49% of participants were White and 42% were People of Colour. In terms of income, 35% of participants had a total household income below $50,000 and 38% reported an income between $50,000 and below $100,000. Table 14.1 provides a detailed description of our sample population.

Table 14.1 Socio-economic and demographic characteristics of participants, N= 82
Full size table

We used the videoconferencing platform Zoom to host online focus groups. One of two senior-level PRA staff moderated each group and at least one of the project leads attended every group, answering any participant questions at the end. Research team members could also unobtrusively send individual messages to the Group Moderator to explore particular aspects as the conversations occurred. Ethics approval was obtained from the University of Manitoba Health Research Ethics Board (H2020:510 linked to H2020:164) and the Research Ethics Board of Toronto Metropolitan University (formerly Ryerson University) (2020:445). Participants gave informed consent to participate in the focus groups and to have any data collected published, including comments made during the focus group discussions. Participants were given the option to choose a pseudonym to be used in publications. Focus groups were audio recorded and transcribed with voice attribution. Transcripts were analyzed using NVivo12, a qualitative research software package.

We developed an initial thematic guide for the focus group sessions in which the moderator asked participants’ opinions regarding implementation of public health guidelines, compliance with infection prevention measures, information seeking behavior and trust, and attitudes toward immunization in general and then specifically the COVID-19 vaccines. In this chapter, we discuss participants’ opinions on the latter theme, focusing on their views about immunization priority groups in Canada. As noted above, as part of the consent process, participants could indicate if they wanted their first name or a pseudonym used in reports and publications. Citations throughout the remainder of this section note in parentheses the city in which the focus group took place, along with the age group to which the participant belonged.

Participants’ Priority Groups

In each focus group, participants were shown a list of population groups and asked to choose three top priority groups to access the COVID-19 vaccine. The focus group moderator then shared the results of the poll with the group and asked participants to explain their choices. The list of available population groups from which to choose included:

  • Healthcare workers (e.g., doctors, nurses, healthcare aides, personal support workers, etc.).

  • People with underlying medical conditions.

  • Essential workers.

  • People living in remote or isolated communities.

  • Indigenous Peoples (First Nations, Inuit, Métis).

  • Seniors (living independently).

  • People living in long-term care facilities (e.g., nursing homes).

  • Educators (teachers, ECE, etc.).

  • Other.

Many priority group rankings aligned with how most jurisdictions were carrying out those early immunization plans: frontline health professionals who actively care for COVID-19 patients and people living and working in long-term care facilities. However, many participants felt that essential workers and people with serious underlying conditions should also be prioritized. When defining what they meant by essential workers, participants spoke in terms of people who have public-facing jobs, particularly those workers who were not in roles where there might be a certain assumed risk associated with that job. For example, someone working as a cashier or in the service sector would never have anticipated their job presented potentially greater risks to their safety prior to the arrival of COVID-19. These same participants equally favoured prioritizing essential workers like first responders and police, because of the public-facing nature of their work. The groups most frequently mentioned as the top three to access the vaccine were healthcare workers, essential workers, people living in long-term care facilities, and people with underlying conditions. Most participants justified their choice by arguing that by virtue of employment they are the most exposed and vulnerable to COVID-19:

Jay::

When COVID cases started building up, the hospitals were getting over packed. [Health care workers] care for people that have COVID, but they care for patients that have surgeries, other infections and other diseases. […] Because if they get COVID, the number of health care workers would be going down and there would be less help and other health workers would have to be pulled to work with COVID patients. So, health care workers should get the vaccine first (Vancouver, 18–34).

Ben::

Healthcare aides or healthcare workers should be first. They would benefit the most from receiving the vaccine. They're the ones who are the most at risk (Ottawa, 18–34).

Two participants, however, noted the dual position of healthcare workers being both at risk of contracting COVID-19 and also posing a risk of spreading the infection into the community:

Riya::

I think I have, oh gosh, six healthcare workers who live in my building of 16 units. And they go to work in a hospital, as well as a retirement facility […] If they contract from somewhere else they’re not going to only just [be] getting people in their retirement home sick […] they’ll bring it back to where they live (Ottawa, 18–34).

Adam::

It is to protect them so that they do not pass it on to people that are vulnerable and people that they are working with who are at a high risk of suffering from COVID (Winnipeg, 35–54).

However, participants also noted that not all healthcare workers have the same importance during the pandemic, nor are they all facing the same level of risk. This is a nuance that is also reflected in the priority groups based on NACI recommendations. Participants identified some healthcare workers as more important to protect than others, such as doctors and nurses working in emergency departments, intensive care units, respiratory therapists, and healthcare aides. Participants also discussed that they would characterize Personal Support Workers (PSWs) working in long-term care facilities in this same category of patient-contact, even if the patient was not COVID-positive, because their work cannot really be done in a physically distant way. Therefore, participants prioritized those healthcare workers who are in closer contact with COVID-19 patients or populations at risk. For example:

Smir::

I am saying emergency staff because they are the ones who just face the patient the first time. They don’t know what they are dealing with. So they might be exposed. I would say that they should be given the vaccine as a priority (Ottawa, 35–54).

Raj::

I would say the PSW because they’re the ones that are going to be doing more the skin-to-skin contact. The people who come into my mom's house and take care of her (Ottawa, 35–54).

Steve::

Healthcare workers like psychiatrists and optometrists that should not be on the priority list (Winnipeg, 55+).

Broadly speaking, the second priority group was often a tie between people with serious underlying medical conditions and essential workers. When discussing essential workers, participants distinguished between workers who were public-facing vs those who were not. Unlike healthcare providers who assume a particular risk when entering the health profession, people who have been declared as essential workers (e.g., security/staff/cashiers in businesses selling essential goods like groceries, pharmacy products, hardware; transit workers, etc.), prior to COVID-19, never assumed such risks. Participants were also sensitized that many of these essential workers are minimum-waged staff who are not typically entitled to sick-leave benefits. Consequently, these essential workers not only carry a greater burden of physical risk, but they also face considerable financial risks if they need to take time from work to self-isolate and/or if they are infected with COVID-19.

Wendy::

People with the most contacts should be given the vaccine first. A Manitoba hydro worker working on some line somewhere is not going to come in contact with a lot of people especially not in winter. A grocery store worker comes into contact with a lot of people. Some of those essential workers might not have sick leave provisions so they might still go to work even when they are not feeling well (Winnipeg, 55+).

Ali::

First responders, ambulance drivers, police are people I would consider as essential workers. They need to go to work. Again, I am choosing my answers based on limiting the spread. To do their jobs effectively, they need to be protected as they protect the community (Winnipeg, 35–54).

Lael::

I also feel like if you can prevent the spread and go from two different angles, those who are at risk and then also those who are the most in front of people then you have your best chance (Ottawa 35–54).

The category most likely to secure third place for priority groups was people living in long-term care facilities. However, people living in long-term care facilities were also some participants’ first and second choice and the reasoning is well characterized by this conversational exchange in a Vancouver group:

Tammy::

I put people in long-term care facilities because of their age and that they have been hit the hardest.

Murray::

I feel the same way. I feel we have been dreadful of taking care of the long-term care facilities. A lot of people did not have COVID but died of starvation and everything else. COVID just brought a lot of those things to light. I think it would be wrong [to] overlook them again in terms of placing them at the back of the line (Vancouver, 55+).

Another participant, however, chose seniors living in long-term care facilities as a priority group because she was willing to sacrifice this group if the vaccines caused serious side-effects:

Rebecca::

I picked people living in long-term care facilities. This is the cynic in me like I really want them to be protected, but if they're not and anybody has to go down at least they're not the ones that are out there taking care of everybody else that's out there working. You know? So, let’s hope it really works (…) but if it doesn’t, we’re not going to devastate our population. Whereas, if we give it to all of our healthcare workers and it doesn’t work, we’re screwed (Ottawa, 35–54).

Some participants who did not choose the same categories as others in their 2nd and 3rd choices, outside of healthcare workers, had a different way of rationalizing their choices in terms of potential vulnerability to more serious effects from COVID-19 as in this exchange in the Toronto 18–34 group.

Calyx::

My thinking was more about people’s vulnerability and targeting the people who were the most vulnerable first. [So people in] long-term care facilities and second I [chose] underlying health conditions—the vulnerable was my thinking.

Kenneth::

I chose essential workers because my criteria was the most potential of getting COVID or most exposure. So my thought was if people who are most exposed to it or had the potential to get exposed to it, get vaccines, maybe there’s less transmission. And then after the first two I was kind of like, the criteria is more about the vulnerable, like who would have the most adverse effect of COVID.

Laura::

I actually think I want to change my answer. I said people living in long-term care facilities but now that I’m looking at the list, I didn’t really think too much about it, but I’m actually thinking now people, and not necessarily just Indigenous people, but people who are living on Indigenous reserves and in those communities have a really hard time getting access to healthcare. And if someone in one of those reserves or communities got sick it would probably spread very quickly and I think that would be in regards to any illness, and the further up north it’s not easy to get to a hospital (Toronto, 18–34).

Contradictions and Cognitive Dissonance

Focus group participants expressed preferences over who should have priority access to COVID-19 vaccines based on who they perceived was facing the highest risk of exposure, serious outcomes, or death. While this reasoning coincides with NACI recommendations for priority groups, participants did not consider equitable access in the same way. For example, only a handful of participants referred to Indigenous Peoples and those living in remote areas, who have reduced access to health care and various resources, as priority groups. A participant, for example, referred to the logistical challenges of delivering the Pfizer vaccine to Indigenous Peoples living in remote communities as a reason to not prioritize this group. At the time of our focus groups, this vaccine was the only one approved in Canada and it needs to be stored at −70 degrees Celsius.

Steve::

I personally don’t think it’s that feasible to get it to them yet. I think the manpower and money that needs to be spent to get them the vaccine rather than the people they know they can get it to right away outweighs it. The stuff has to be kept at minus 70 degrees. How can they do that when they’re transporting it up north? You just can’t so I think it would be a waste of resources (Winnipeg, 55+).

Those participants who considered Indigenous populations a high-risk group, however, emphasized poverty, inadequate housing and lack of health care as conditions putting Indigenous Peoples on and off reserves at greater risk of COVID-19. For example:

Margaret::

I would say Indigenous people should be on the priority list. Indigenous people living in the north are living in poverty, substandard housing and have poor access to health care. They are extremely vulnerable and many have other health conditions as well. I believe those populations should be prioritized. For Indigenous people living in the city—we have a high population in Winnipeg—and unfortunately they also make a significant portion of our vulnerable population and might be homeless or living in poverty, so those also need to prioritized (Winnipeg, 55+).

Bryna::

I chose [Indigenous Peoples] because they’re a group that is more likely to acquire COVID and are very, very vulnerable. Many of them live in very cramped conditions. And I just think they deserve a break once in a while, they don’t get many breaks (Ottawa, 55+).

However, some of our Indigenous participants in other groups, while acknowledging that they themselves would likely get the COVID-19 vaccine once available to them, highlighted that Indigenous Peoples more generally are hesitant about getting a COVID-19 vaccine as a priority group because of negative historical experiences. This was well described by one participant who self-identified as First Nations:

Leeann::

I didn’t choose them [First Nations, Inuit, Métis Peoples] because they’re very hesitant and superstitious about getting the vaccination. I’ve spoken to members of the community. It’s just based on history. They’re very hesitant to take the vaccine if it’s available. It’s not that they won’t, it’s just that they’re very hesitant. So instead, I picked people who are living in remote or isolated communities. It would be the same for Indigenous populations because a lot of our communities are remote. We have a whole First Nations that moved all their long-term care patients down to [a southern city] because they just don’t have the medical facilities to deal with COVID. At the beginning of COVID a lot of the First Nations closed their doors to people coming in and out even if we were members of our communities, we could not go home. Because the First Nations only would allow people who resided in the First Nations 100% of the time into their communities. However, now we’re seeing a mass outbreak in our First Nations communities which is devastating because they don’t have the running water, they don’t have the hospital or facilities, they don’t have the medical personnel to deal with the outbreak that they’re having now (Ottawa, 55+).

Contextualizing participant perspectives on prioritization for early access to COVID-19 vaccines is important. For example, despite clearly identifying priority groups as populations that should be protected and therefore should have early access to the vaccines, focus group participants also expressed doubts about the very vaccine they were willing to give to the most essential or most vulnerable. Many participants said that they themselves would not get vaccinated if eligible and instead they would rather wait for others to be immunized first to make sure COVID-19 vaccines are safe.

While a little over half of participants (56%) were strongly confident in decisions to receive a COVID-19 vaccine once it was their turn to be offered one, others had some open questions and wanted more information. Within this “wait and see” group, the time they felt comfortable in waiting ranged from 3 months to 1 or more years. However, their narratives suggested that several things were underlying their position: (1) feeling the vaccines were “rushed” and not tested enough, as well as some being genuinely unfamiliar with how agencies like Health Canada made assessments about vaccine safety and effectiveness prior to issuing authorizations; (2) wanting more safety data and general effectiveness data outside of clinical trial phases based on vaccine roll out to priority group recipients; (3) information about how effective COVID-19 vaccines were against emerging new variants; (4) more open and complete information about individual vaccines, particularly, as more vaccines would be approved over time; and (5) some generally felt their age or general health would allow them to weather any serious complications of contracting COVID-19 and therefore felt the uncertainty inherent in the risks of new vaccines was greater than the risk of the disease. Exploring participant perspectives of vaccine acceptance will be the subject of a future publication and will not be addressed in greater depth here.

Discussion

The COVID-19 pandemic has had a greater impact on racialized minorities in Canada (Public Health Agency of Canada, 2021), triggering calls to reduce health inequities, including vaccine access. Canada has shown a commitment to equitable distribution of vaccines through NACI guidelines, the way in which provinces developed priority groups, ensuring those facing a higher risk accessed the vaccine first, and also in the country’s commitment to COVAX. Similarly, provincial and territorial governments sought to prioritize, first, those at higher risk of infection, followed by vaccine access to Indigenous Peoples and those who live in zones of higher transmission.

In our focus groups, however, participants’ understanding of fairness and equity were variable and sometimes contradictory. Focus group participants identified some groups as facing higher risk of infection and death and therefore were willing to grant them priority access to a COVID-19 vaccine. The level of risk in the focus groups was determined mainly by age and contact with patients. However, other factors that cause health inequities were mostly disregarded, for example, poverty, racial discrimination, inadequate housing, or living in remote areas. In general, participants did not consider Indigenous Peoples a priority group.

With the initial production and approval of COVID-19 vaccines, developed nations around the world rushed to acquire as many doses as possible to protect their citizens, while developing countries, two years after the first vaccines were distributed, continue to face formidable challenges in their efforts to procure enough vaccine doses (World Health Organization, 2021). About 30% of the world population remains unvaccinated against COVID-19 (Holder, 2022). In this context, being eligible and having access to a COVID-19 vaccine is a privilege, particularly in Canada where the vaccines are funded through the public healthcare system. Many focus group participants, however, were not convinced about the safety of the vaccines despite the rigorous safety checks conducted by Health Canada prior to approval. These participants were unwilling to get vaccinated and adopted a “wait-and-see” approach, delaying their decision until more people had been vaccinated and had assumed the risk of potential side-effects of the vaccines. This vaccine hesitancy was not unique to our focus group participants but has been expressed by many Canadians, particularly those between the ages of 55 and 65, who rejected the AstraZeneca vaccine due to case reports of extremely rare clot disorders following vaccination (Cohen, 2021; Lofaro, 2021; Neustaeter, 2021).

Public engagement is a key aspect of health policymaking and risk communication (Hu & Qiu, 2020). Involving citizens in decision-making processes fosters trust and acceptance; however, there are some limitations to public engagement. First, engagement efforts tend to be self-selective, thus the same groups of people participate in these consultations, which amplifies their voices in detriment of others. Second, while fairness, equity, feasibility, and acceptability are all key components in health policymaking, in our focus groups we found that the general population rarely shares the same concerns and can often hold contradictory views simultaneously. In the focus groups, participants who were unwilling to be vaccinated due to vaccine safety concerns were eager to prioritize groups they considered especially vulnerable or as playing a crucial role in health care.

Conclusion

In times of vaccine scarcity, prioritization of vaccine access is a difficult task and the recommendations will not satisfy everyone. NACI released a set of recommendations based on application of its EEFA framework as well as expert and stakeholder engagement and public engagement. Nonetheless, it is entirely in the purview of provinces and territories to establish the implementation of immunization programs in their jurisdictions. The variability in the application of NACI recommendations was evident in the three provinces highlighted in this chapter. Assessing public preferences for prioritization through our focus groups equally highlighted the fundamental tensions that arise when engaging citizens who generally enjoy greater privilege in society (where privilege is defined as unearned benefits ascribed to an individual on the basis of their race, ability, gender, sexuality, and so forth).

Interestingly, the concept of “vulnerability” was the primary reasoning behind any prioritization recommendation regardless of source. Vulnerability was defined in terms of three factors: exposure, medical vulnerability, and disproportionate risk. Exposure vulnerability was based on a greater chance of exposure as a consequence of employment, which would capture healthcare workers who care for patients who have COVID-19 and essential workers (e.g., grocery workers, paramedics, etc.) who interact with the public at large, often for low pay and/or without sick-leave benefits. Medical vulnerability was defined as being at greater risk for more severe disease and death, which would capture people with serious underlying medical conditions and people of (often) advanced age living in long-term care facilities. Disproportionate risk vulnerability was defined as people living and working in conditions that put them at greater risk of infection with potentially disproportionate consequences, such as Indigenous Peoples. Yet, as Lemyre and colleagues (Lemyre et al., 2009) explain, there is a critical difference between vulnerability in terms of susceptibility, where people are more likely to become infected because of differential exposure, and sensitivity, where people are more likely to become seriously ill or die if they become infected.

NACI recommendations and stakeholder preferences focused first on sensitivity (underlying medical conditions, advanced age) before susceptibility (workers at greater risk of exposure due to environment). They also made efforts to address health inequities through the inclusion of Indigenous Peoples. Indigenous Peoples are both more susceptible to severe disease due to their living environments, often created through a shared colonial history of harm and trauma, as well as more sensitive due to a higher rate of multiple underlying chronic conditions relative to the general population. Subsequent waves of Canadian attitudes expressed through public opinion surveys, favoured susceptibility (through preferences for healthcare workers) over sensitivity (people of underlying conditions, advanced, age, etc.) (Impact Canada, 2021). The attitudes expressed in our public focus groups shared a similar pattern to that of Canadians overall. While acknowledged by NACI, considerations to address underlying inequities that are disproportionately borne by Indigenous Peoples and racialized groups, were rarely identified by focus group participants, and inconsistently reflected in the vaccine implementation plans of different provinces and territories. In fact, provinces and territories, unequally and selectively prioritized those who are at greater sensitivity (age, underlying medical conditions for those living in long-term care facilities, Indigenous populations) and focused mainly on susceptibility through risk of exposure (healthcare workforce).

There are several recommendations stemming from this work. First, it is important that independent bodies tasked with prioritization continue to go beyond systematic evaluations of evidence in terms of disease burden to include both expert/stakeholder groups and the public. This will aid in both informing and defining relevant values and perspectives. Second, when engaging broad audiences it may be important to discuss the relative weight each group should carry in informing final suggestions. The general public, as an entity, is challenged in its ability to represent all facets of diversity. Even with making efforts to ensure broader engagement, the capacity to engage those who are more marginalized in society is difficult, and almost impossible using typical public opinion methods (e.g., surveys and focus groups of reachable, willing and able participants). Without better ways to engage citizens living at the margins of society, public opinion tends to be fraught with contradiction and does not always consider all the key guiding principles of fairness and equity. Third, provinces and territories, as the jurisdictions ultimately tasked with making decisions after considering recommendations, need to be open and transparent in all their decisions for the inclusion/exclusion of different groups. In the three provinces focused on in this chapter, there was considerable variability in application of priority groups outside of general age considerations. With the explosion of new variant COVID-19 cases by May of 2021 some jurisdictions started prioritization of geographic “hot spots,” which often included racialized populations. These decisions to increase vaccine access need to be accompanied by redirection of vaccine supply and other considerations, lest these moves appear to be more symbolic than genuine efforts to address inequities. As the SARS-CoV-2 virus continues to evolve and new variants emerge, new bivalent vaccines are being approved, targeting more than one strain (Canada, 2022). The initial implementation of the COVID-19 vaccine rollout provides important lessons that need to be documented and factored into plans for distribution of bivalent COVID-19 vaccines and for the next PHEIC event.