Royal society of Canada COVID-19 report: Enhancing COVID-19 vaccine acceptance in Canada

Vaccine confidence amongst Indigenous Peoples in Canada is also complex. Distrust is linked to the violence of colonialism (Mosby and Swidrovich 2021) where historically, Indigenous Peoples nearly met annihilation as a result of vaccine preventable diseases such as smallpox, diphtheria, polio, and tuberculosis as vaccines came late to many. Settler governments stripped Indigenous Peoples of their lands and the right to self-determination, confining many to isolated reserves. Generations of segregated substandard services were provided by a federal government who had the constitutional fiduciary responsibility for housing, education, and health care. Medical experimentation and abuse were commonplace for children in residential schools and children and adults in “Indian hospitals” and other hospitals (MacDonald et al. 2014; Collier 2017; Mosby and Swidrovich 2021).

Memories of these atrocities have been passed along generations with the legacy of colonial violence persisting today in the health and social inequities remaining (Greenwood and MacDonald 2021). Long-ignored social problems and problems stemming from government neglect of treaty and nontreaty obligations remain an emergency for Indigenous Peoples and communities.

These historic and present-day inequalities cannot be separated from Indigenous Peoples’ experiences with COVID-19 infection, initially disproportionately higher rates compared to non-Indigenous and questions about COVID-19 vaccines. Community leaders and elders have worked very hard to implement COVID-19 public health strategies for control including vaccine. Concerns have been addressed, distrust overcome to garner support for vaccine uptake on and off reserve leading to high acceptance rates in many communities and better control of COVID-19 (Government of Canada 2021e).

In the United Kingdom, United States, and Canada, racialized groups, including Black communities have been disproportionately affected by COVID-19. Canadian neighbourhoods with the largest proportions of visible minorities reported higher COVID-19-related mortality (Statistics Canada 2020a). In the Greater Toronto Area (GTA) of Ontario, as of December 2020, Black individuals accounted for 9% of the population and more than 21% of reported cases of COVID-19 during summer 2020. In contrast, the White population accounted for 48% of the population of the GTA and 17% of COVID-19 during summer 2020 (Toronto 2021). Other racialized groups are also disproportionately affected. In Ontario’s Peel region, South Asians account for 32% of the population and 59% of COVID-19 cases compared with Whites who account for 37% of the population and 13% of cases (Region of Peel 2021). Major contributing factors to these disproportionate rates for those affected by COVID-19 spill out from the social determinants of health.

Persons experiencing homelessness have a higher prevalence of physical illness, mental health challenges, and addiction/substance abuse related concerns. Many are at higher risk for COVID-19 illness due to congregate living as well as often limited ability to utilize nonpharmacological COVID-19 prevention strategies (e.g., masks, social distancing, and frequent handwashing) (Turnbull et al. 2021; Baggett and Gaeta 2021).

Homeless youth are especially vulnerable (Karabanow et al. 2007). Approximately 20% (nearly 40,000) of Canadians experiencing homelessness are youth between 13 and 24 years of age. Most of these youth are victims of poverty and neglect, child abuse, and (or) violence. These circumstances are often due to system failures, with over 50% of youth having a long history in the child welfare system. Additionally, 12% of youth who experience homelessness have a physical disability, 18% suffer from addictions, and 39% have mental health issues. Homelessness is disproportionately higher among LGBTQ2S, Indigenous, and Black youth.

Youth who experience homelessness also experience a high incidence of infectious diseases, some of which are vaccine preventable. However, early departure from school, limited access to public health services, few youth-focused shelters, and high mobility makes these youth a vulnerable and extremely hard to reach group compared to other Canadians, including older homeless populations. Additionally, immunization may be seen as a low priority for these youth who tend to exist in a day-to-day survival mode precariously seeking out food, clothing, safety, shelter, and income. Furthermore, homeless youth may have additional concerns that push back against vaccine acceptance such as limited access to health care services (often due to a distrust of formal health systems), perceived and real discrimination by health care workers, lack of identification, worries of confidentiality breeches, and fears of being reported to law enforcement authorities.

Major challenges to access to vaccination can occur in persons living with a disability and (or) those who are reliant on home care to support their independence in the community. Factors that may affect the ability to come forward to immunization include (1) Geographic location: How far does the person have to travel to the vaccination site? (2) Transportation: Who is responsible for arranging transportation to the vaccination site? (3) Accessibility: Is there priority access to facilitate the vaccination process? Is the site wheelchair accessible? Does the site have the capacity to obtain consent to vaccination and administer the vaccine to those who are hearing or visually impaired? (4) Caregiver support: What happens if the person refuses to come forward because their care and support is provided by an unvaccinated home care worker and they are deeply concerned about the COVID-19 risks with the home care being offered?

Of concern but not discussed above are those in the population who may not be large enough in any one region or jurisdiction to be recognized to receive attention as an equity deserving group e.g., migrant workers, undocumented migrants. These groups need attention and development of strategies tailored to address their concerns and fit their needs.

Religious communities are among the cultural forces that socialize members into ethical frameworks that help them make both mundane and heavily freighted decisions. Religious communities are themselves so profoundly diverse that grouping them together is problematic. Nevertheless, none of the major religious traditions with which most are familiar eschew vaccines. In fact, religious institutions and leaders across communities overwhelmingly see vaccines as being consistent with internal values such as caring for others, preserving life, and having a duty to community (Grabenstein 2013). Nevertheless, religious concerns about immunization have been raised since the late 1700s when vaccination was introduced into western medicine. Recent scholarly work (Bramadat et al. 2017) and surveys by the WHO and UNICEF (Lane et al. 2018) found that religious concerns were often inextricably bound up with the delay in vaccine acceptance we see with infant and childhood vaccines globally. The impact on vaccine acceptance across the age span is unknown but likely similar to children. In Canada formal religious concerns have not been especially prominent in vaccine acceptance survey data, but there have been outbreaks of vaccine-preventable diseases in some religious communities that eschew some aspects of conventional health care, including immunization. For example, a recent study (Wilson et al. 2021) on vaccine acceptance by school age children from Ontario revealed that hot spots for under-immunization were often clustered and in some instances closely associated with specific religious communities. With respect to COVID-19 vaccines, the Canadian Conference of Catholic Bishops initially stated in early March 2021 that “parishioners should try to avoid taking viral vector vaccines like those produced by AstraZeneca-Oxford because they were developed using cell lines that may have been derived from an abortion nearly 50 years ago” (CBC 2021a). The impact of this advice on vaccine acceptance is still unknown. Of note this advice was clarified a week later stating “all COVID-19 vaccines that are medically approved by the relevant health authorities may be licitly received by Catholics” (CBC 2021a). Importantly, none of the viral vector COVID-19 vaccines contain any fetal tissue. There are concerns, however, that Canada may see similar push back to COVID-19 immunization from evangelical Christians as has been seen in the US (The Conversation 2021). Amongst these are many who are anti-science, anti-government, and believe in conspiracy theories about COVID-19 (McLaren 2020). Time will tell, but the flouting of COVID-19 public health guidance on public gatherings by some large religious congregations is not encouraging (Little 2021). This may have more basis in civil disobedience than in specific religious concerns.

Each of these community examples noted above underlines the complexity and diversity of factors influencing potential COVID-19 vaccine acceptance at the person level; the importance of who offers/recommends the vaccine, the value placed on these vaccines in the community, the knowledge about COVID-19 vaccine risks and benefits, the perception of COVID-19 risk in their context, ease of access to the vaccine, the recommendation or lack thereof by a valued civil society organization. They also highlight the importance of tailoring strategies for COVID-19 immunization for these communities. One plan does not fit all. For example for the homeless, a targeted, flexible, contextual, and culturally unique approach is needed—not a mass vaccination clinic blitz (Ghosh et al. 2021a). The outcome of a scoping review on vaccinating the homeless has highlighted key strategies (Ghosh et al. 2021b).

A major influencer of vaccine acceptance is the strength of the health care worker’s recommendation (Giambi et al. 2018) and how this is done, i.e., use of a presumptive rather than participatory introduction (Opel et al. 2013): “Today you are scheduled to receive a COVID-19 vaccine” not “What would you like to do about the COVID-19 vaccine?” Health care workers have long been seen as a most trusted source of information for vaccines and are noted to be trustworthy in surveys for COVID vaccines (Costa-Pinto et al. 2018; Nguyen et al. 2021). There are caveats, however.

Whether a health care worker is immunized for routine immunization also affects their recommendations for vaccination (Karlsson et al. 2019). This likely holds true for COVID-19 vaccines as well. Hence, ensuring high rates among health care workers is of critical importance (see below) (Zhang et al. 2010; Collange et al. 2016). All health care workers are not the same; there is a range in vaccine acceptance amongst different health care workers (Crawshaw et al. 2021; Desveaux et al. 2021; Dzieciolowska et al. 2021). Physicians and health care managers were more likely to accept vaccination compared to nurses.

In an unpublished Canadian survey in 2020, factors shown to be important in influencing health care worker intent to have a COVID-19 vaccine were vaccine safety, vaccine effectiveness, trust in the regulatory process, recommendation from NACI, personal risk factors, recommendation from their local public health authority, and recommendation from their professional association. Home care workers who are unimmunized may also impact on their clients’ decisions to accept vaccine as well as adding to their risk of contracting COVID-19, as what any health care worker says can impact patient vaccine acceptance.

Health care workers not only need regularly updated knowledge about COVID-19 disease and vaccines so they can be well placed to address queries raised by patients, but they also must also understand immunization best practices to optimize acceptance. Communities and groups who have been disrespected and (or) stigmatized when coming forward for health care by the health care workers are unlikely to trust easily. Immunization ambassadors from within the community, community members who champion vaccines, can help. Health care workers can play a role in helping to allay fears and grow trust in the vaccines by respecting lived experiences, past histories, and tailoring interaction to fit the person and the group. Training on best practices in addressing a vaccine-reluctant patient such as motivational interviewing (Gagneur 2020) is needed. For addressing specific vaccine safety concerns health care workers need ready access to up-to-date science-based answers to relevant questions. Currently this is not easy. Much time is needed for online searches, consultation on reliable and trusted web sources, as well as paying attention to the formal and social media to know what are key questions of the moment and what should be their science and evidence-informed responses. For busy frontline health care workers, this can be a major roadblock in willingness to counsel and work with vaccine reluctant patients.

The COVID-19 disease and vaccine infodemic (WHO 2021f) mis/disinformation is undermining vaccine acceptance (Section 4.4.2). Health care workers themselves may be influenced (Tomboloni et al. 2019). When patients bring up concerns raised by this mis/disinformation, health care workers need to debunk the myths (The Debunking handbook 2020), provide accurate up to date science based information (MacDonald 2020), and if able address the misinformation on social media and report this to providers. The WHO provides guidance on how to do this (WHO 2021d). Words used to discuss mis/disinformation and those promulgating it need to be chosen with care (Section 4.4.1). As noted above, a gap in easy access for health care providers to evidence-based answers to questions patients raise alerts to “hot” mis/disinformation topics and the science to address them could help health care workers to more efficiently and effectively counsel patients on COVID-19 vaccines.

Common concerns about all vaccines including COVID-19 vaccines relate not just to their safety but also to the nature of their delivery. For example, the discomfort associated with their administration—the needle stick—is an issue for many people. In Canada, about 1 in 4 adults report they are afraid of needles to some degree and about 1 in 10 report that concerns about needle stick pain and fear influence their decision about getting vaccinated (Taddio et al. 2012). Addressing needle-related pain (Taddio 2021) and fear (Meghan McMurtry 2021) using evidence-based interventions (Taddio 2021) to help make the experience as positive as possible (Taddio 2021), especially with COVID-19 vaccines as some need two separate doses, are other key knowledge components for health care workers tasked with vaccine delivery.

Vaccines are held to a very high safety standard because of their important role in the control of serious infectious diseases. Canada has a robust vaccine safety system with rigorous testing required in preclinical and clinical trials followed by careful pre-approval scrutiny of the clinical trial data to determine if the vaccine should be approved, and if so for whom, how, and when (MacDonald and Law 2017). These pre-approval trials must be large enough to determine efficacy, and to identify common adverse events. If the vaccine is not efficacious, or if there are common serious adverse events attributable to it, then the vaccine does not receive approval. Canada’s post-approval safety surveillance system is largely structured and undertaken at the provincial level. For children there is a paediatric hospital-based national active surveillance network for detection of vaccine failure, serious AEFIs, and selected infectious diseases that are, or will be, vaccine preventable (IMPACT) (Bettinger et al. 2014). Data collection is standardized, the nurses who collect it are well trained, and the assessment of the data is rigorous. In contrast, detection of serious AEFI in adults as needed for COVID-19 vaccines is primarily a passive system, which means that health care workers are expected to recognize a serious AEFI and then report it (Harmon and MacDonald 2020). It is unclear how many health care workers know about this responsibility and its importance. More work is needed to not only educate health care workers but also at the program level to make AEFI reporting, investigation, and causality assessment a stronger program (Harmon and MacDonald 2020).

A key point to recognize is that the public looks to a wide range of health care workers for advice, not only nationally regulated health professionals such as nurses, doctors, pharmacists, etc., but also those not nationally regulated such as paramedics and personal care workers, and those in environmental services. Given the complexity of factors that can affect COVID-19 vaccine acceptance, health care workers need education about key roles they play in their interactions with all patients, education on COVID-19 disease and vaccines, as well as on AEFI and on a range of communication skills needed when addressing immunization and vaccine acceptance issues to optimize interactions with patients and support vaccine acceptance. Given the wide variation in immunization education backgrounds for different health care professionals—both regulated and unregulated—the level of knowledge and skills differ widely, hence education needs differ widely. Work is needed to develop tools and easily accessible training modules to address different health care workers’ knowledge and skills gaps as well as best practices to facilitate health care workers being up to date as the science evolves.

The large scale of the COVID-19 vaccine rollout campaign means that many health care workers will be involved, including some with limited training on immunization. It is essential that these workers be trained to competently deliver immunizations safely using best practices and equipped to adequately address questions and worries of people coming in the clinics (e.g., people refusing the Oxford AstraZeneca vaccine because it is perceived as less effective). In contrast to the clinical trials, which had different end point, in “real world effectiveness” both the Pfizer and AstraZeneca vaccines were shown to both be very effective in preventing hospitalization and death (Torjesen 2021a). To understand this health care workers must understand the difference between efficacy and effectiveness, well explained in a US National Academies of Sciences, Engineering, Medicine report that also provides communication strategies for explaining this for COVID-19 vaccines (Lowry 2021). WHO also has a report in March 2017 on COVID-19 vaccine effectiveness criteria (WHO 2019a). Similarly, the very rare serious adverse event of thrombosis with thrombocytopenia with the AstraZeneca (Government of Canada 2021b) and Jannsen (FDA 2021) vaccines needs to be explained in context with risk of serious complications including thrombosis with COVID-19 disease. Not a simple task.

Given the important role health care workers have in vaccine acceptance as noted above, (Zhang et al. 2010; Collange et al. 2016) every effort needs to be made to optimize health care worker COVID-19 vaccine acceptance. Strategies need to be in place to determine the barriers and enablers. Listening is key as is co-creation of the programs. As with the general public, multi-pronged strategies are likely to be more successful than a single strategy and the reasons for hesitancy or delay should not be assumed. Local vaccine champions may be very helpful. Delay in acceptance may be linked to lived experiences (black, Indigenous, religious, etc.; Section 3.2.1) and needs appropriate respectful approaches. Barriers to access such as need for paid time off etc. need to be addressed not only for health care workers but for all employees.

COVID-19 disease and vaccine science are evolving. Access to needed information for health care workers, program managers, decision-makers, and the general public must be easy, and the information updated regularly as the science evolves. Health care COVID-19 vaccine program managers and health care workers need accurate, reliable, and up-to-date data and evidence on COVID-19 disease and the COVID-19 vaccines to revise programs and answer questions raised by people coming forward to be immunized. The public needs to know why, based upon what evidence, decision-makers have come to their recommendations, if these are likely to change, and if so when and why. When advice does change, care must be taken to explain the new evidence that supports this change. A major issue with COVID-19 vaccine information for vaccines approved in Canada is that the clinical trials did not all use the same end points nor end point definitions, that preliminary results are in the news even before peer review, and much of the evidence is highly technical making interpretation more difficult. Furthermore, self-proclaimed experts on COVID-19 vaccines and their best use abound. There has been a lack of coherence in recommendations for the use of vaccines (Section 2.2). Based on limited data, the regulator, Health Canada, and the independent NACI, arrived at different conclusions on whether to recommend the Oxford/AstraZeneca COVID-19 vaccine for adults over 65 years of age. This discrepancy was further compounded by different provinces then moving forward with different strategies for this vaccine with one a yes for use in those over 65 years (Quebec) the others a no. The NACI advice changed in March 2021 as real-world effectiveness data for that older age group became available (Government of Canada 2021a) and changed again in April 2021 as the science evolved (Government of Canada 2021b).

This subsection outlines legal frameworks critical to vaccine acceptance, equitable access, and uptake. These human rights frameworks support that, in the absence of health, individuals cannot participate in valued social activities from forming families, to performing work, to contributing to culture. Indeed, there is a link between poor health and social/political instability (Ruger 2006). Therefore, vaccines are viewed as “global public goods” meant to contribute to the equitable protection of peoples, and the WHO has offered a values framework for COVID-19 vaccine roll-outs that encompasses human wellbeing, equal respect, equity, reciprocity, and legitimacy (WHO 2020d).

The Universal Declaration of Human Rights 1948 (UDHR) states that the inherent dignity and equality of all members of the human family is the foundation of freedom, justice, and peace, and that all humans are born free and equal in dignity and rights, are endowed with reason and conscience, and should act towards one another in a spirit of solidarity (UN 2021a). The UDHR informs the International Covenant on Economic, Social and Cultural Rights 1966 (ICESCR) (UN 2021b), in force in Canada, and both are components of the International Bill of Human Rights (IBHR).

Two IBHR provisions are implicated by the COVID-19 pandemic. Article 12 (ICESCR) articulates the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, and directs states to realize this right through multiple interventions, including those aimed at the prevention, treatment, and control of epidemic, endemic, occupational, and other diseases, and the provision of medical service. This right to health is reiterated in multiple international instruments. Article 15 (ICESCR) articulates the right of everyone to enjoy the benefits of scientific progress and its applications, imposing on States the diffusion of science and culture through multiple means. It recognizes science as a “public good”, and the benefits of science as the heritage of humanity (Morsink 1999). It places well-being at the centre of any justification for pursuing science (Chapman 2009).

The rights that are directly enforceable in Canada must find voice in Canadian law, which should, and more or less does, reflect the above instruments. The Canadian Human Rights framework is represented by the Canadian Charter of Rights and Freedoms (Charter) (CanLII 1985), and the Canadian Human Rights Act (RSC 1985), and together with its Provincial/Territorial counterparts, seeks to eliminate discrimination by private actors.

The Charter extends to those in Canada a range of rights, and imposes on governments and government actors, and on those carrying out governmental functions, duties to refrain from unduly infringing upon those rights in pursuing their public functions (Supreme Court of Canada 1990). However, the Charter does not enumerate a right to health or health care. Having noted that, there is scope to interpret existing Charter rights—to life, liberty, and security of the person; to equality; to freedom from cruel treatment—so as to advance a right to equitable access to (reasonable levels of) health care in keeping with the IBHR.

Actions taken across Canada to overcome COVID-19 have interfered with the exercise or enjoyment of rights (e.g., mask-wearing orders (s 7), border checkpoints (ss 8 and 9), etc.). However, all of our rights and freedoms are subject to “such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society” pursuant to s 1 (Flood et al. 2020). This means that all Charter rights, regardless of whether they have internal limitations (many do), are limited by the nature of our democratic state, and by the needs associated with preserving and improving that democratic state in diverse conditions. Governments are entitled to take measures to protect public health, even if those measures infringe certain rights, so long as there is sufficient evidence supporting their actions (i.e., demonstrating that they are effective, proportionate, and minimally infringing or intrusive) (Flood et al. 2020). Essentially, public health decision-makers must base their interventions on evidence and wide-ranging risk analyses, and they are expected to communicate the basis for their actions clearly. Canadian governments have faced criticisms in this regard with respect to a wide range of their interventions.

Contrary to the Charter, human rights legislation applies to governments—in their performance of certain tasks and provision of various services—and to private actors (i.e., employers, unions, landlords, businesses, etc.). Individuals and groups can initiate discrimination claims that are then investigated by the relevant Human Rights Commission, which, if a claim is accepted, fashions a suitable remedy. Discrimination can be defined as differential treatment of an individual or group, whether intentional or not, based on grounds relating to personal characteristics, which has the effect of imposing disadvantages not imposed upon others or that withholds or limits access to opportunities available to others (Supreme Court of Canada 1989; this general definition is relevant to discrimination whether claimed under the Charter right of equality (s 15) or human rights legislation). Distinctions based on immutable personal characteristics, or aspects of the person that can only be changed at unacceptable cost, that are attributed to an individual solely on the basis of association with a group will often be classed as discriminatory.

To succeed in a discrimination claim under human rights legislation, claimants have to show (1) that they are a member of group protected under such Acts (e.g., a group characterized by religion, creed, ethnic origin, sex, genetic characteristics, disability, etc.), and (2) that they were subject to adverse treatment for which that prohibited ground was a factor (Supreme Court of Canada 1999). If an employer were contemplating mandated vaccination, for example, an employee might claim that vaccination is contrary to their religious beliefs or creed. Assuming the Human Rights Commission (or Tribunal or court) accepts this, the employer would then have to justify the mandate by showing that it is a bona fide occupational requirement (BFOR). To do this, the vaccination must be: (1) rationally connected to the performance of the job, (2) adopted in an honest and good faith belief that it is necessary to the fulfilment of that legitimate work-related purpose such as hospital and home care workers providing care to patients/clients at high risk for serious illness with COVID-19, and (3) reasonably necessary to accomplish that legitimate work-related purpose. Mandated influenza “vaccination or mask” policies for health care workers have been struck down in British Columbia (HEABC 2019) and in Ontario (Cavalluzzo 2015). In these cases, the policies were held to represent a breach of the Collective Agreement, and an unreasonable exercise of management rights. Arbitrators have also accepted that there is insufficient scientific evidence to support the effectiveness of “vaccinate or mask” in relation to asymptomatic transmission of seasonal influenza. Importantly, these arbitral decisions do not negate the validity of mandates. Instead, they speak to the fact that the mandate should have some scientific basis (re: effectiveness of the mandated action), and it cannot be contrary to already agreed working conditions.

Indigenous Peoples habitually face higher-than-average rates of disease burden, poor access to essential services and health care, and sub-standard health care interventions, which are often tainted by stigma and prejudice (UN Department of Economic and Social Affairs 2021). The COVID-19 pandemic poses an increased threat to Indigenous communities in Canada, who have experienced a case rate 40% higher than that in the general population (Somos 2021). This despite the fact that the UN Declaration on the Rights of Indigenous Peoples (UNDRIP) (UN 2007; Canada originally voted against the Declaration due to concerns around land claims and resource development, but acceded to it in 2010, characterizing it as an “aspirational” document) recognizes them as free and equal, and having the right to the full enjoyment of all human rights (UN 2007). The UNDRIP also states that Indigenous Peoples have the right to self-determination and self-government (UN 2007), and that Indigenous individuals have the right to life, liberty, security of the person, and physical and mental integrity (UN 2007). With respect to health, Indigenous Peoples have the right to the improvement of their social conditions, including housing, sanitation, health, and social security, and states have a duty to adopt effective measures to ensure improvement of their conditions, with particular attention the special needs of elders, women, youth, children, and persons with disabilities (UN 2007).

However, again, it is domestic law that more directly shapes the experience of Indigenous Peoples in Canada, and the Canadian government has characterized the UNDRIP as “aspirational” (Henderson and Albers 2020). Despite the constitutional recognition of self-government (see, Government of Canada 1982, which recognizes and affirms existing aboriginal and treaty rights, including land claims that exist or may be acquired), self-government advancements have been modest and incremental (i.e., there are 25 self-government agreements involving 43 Indigenous communities, and two education agreements involving 35 Indigenous communities) (Government of Canada 2020), and the resources for these communities to respond effectively to events such as the COVID-19 pandemic have not been made available (Power et al. 2020). Indeed, health data disaggregated by ethnicity is rarely collected despite such data being essential to understanding the true impact of COVID-19 on these communities and on tailoring services so that they are more equitably serviced going forward (Kauh et al. 2021).

At present, health care for Canada’s Indigenous Peoples (First Nations, Inuit, and Métis) is delivered in a piecemeal fashion, with federal and provincial governments sharing responsibilities (and often passing the buck to the other to the detriment of the patient (Blackstock 2016)). The result has been significant shortfalls and inequalities in service and health outcomes (Nader et al. 2017; Wylie and McConkey 2018). Acknowledging the significant health gap between Indigenous and non-Indigenous populations in Canada, the Government of Canada has implemented the Non-Insured Health Benefits (NIHB) program for First Nation and Inuit people to help cover the costs of medically necessary services and interventions, and some provincial programs also exist, but health disparities remain, as do significant barriers to improved outcomes (Nguyen et al. 2020).

As noted above, discrimination can be defined as differential treatment of an individual or group, whether intentional or not, based on grounds relating to personal characteristics, which has the effect of imposing disadvantages not imposed upon others or that withholds or limits access to opportunities available to others (Supreme Court of Canada 1989). Distinctions based on immutable personal characteristics, or aspects of the person that can only be changed at unacceptable cost, that are attributed to an individual solely on the basis of association with a group will often be classed as discriminatory. Individuals from certain groups have historically been disempowered or “marginalized” by and within society and have therefore been viewed as at higher risk or as “vulnerable” to unfair treatment, both intentional and unintentional (and often systemic). Some of them now have recourse to special legal frameworks.

Targeted COVID-19 vaccination campaigns have led to high vaccination rates of those with clear capacity and ease of access to the immunization site where the vaccines are being delivered. To facilitate uptake of COVID-19 vaccines, the consent process needs to be efficient, informed, and free of coercion. It should be sensitive to the needs and context of the person and not serve as another barrier to vaccination.

Consent in most circumstances will be relatively straightforward. In the usual course, capacity to consent is presumed unless there are circumstances which make this presumption unreasonable. Individuals deemed to have capacity have the right to consent or withhold consent to any medical treatment or to withdraw consent even if it is contrary to medical recommendations (Supreme Court of Canada 1980; Supreme Court of Canada 1993). This common law right, which is legislatively embedded across Canada, stems from constitutional principles of dignity and autonomy (Supreme Court of Canada 2013).

Matters become more complicated when capacity is in issue (i.e., minors, those in long-term care where rates of dementia are relatively high, and those in community care where cognitive and physical disabilities may limit capacity). In such cases, the capacity assessment must be contextual and specific (i.e., related to the event or intervention at issue, such as COVID-19 vaccination), and they may be carried out by medical doctors, psychologists, or nurses, occupational therapists, or social workers trained and certified to carry out capacity assessments. For the factors to be considered, reference must be had to legislation specific to the province and the context because the rules around consent, and around consent on behalf of another, varies by jurisdiction and policy field.

Most provinces have a general statute that sets the age at which minors become adults with full rights to exercise autonomy. However, some Provinces/Territories set the age at 18, and others at 19, with no justification offered for the divergence (for a useful province-by-province summary, see Coughlan 2018), and the threshold age for making decisions may differ within a province depending on the setting. For example, under the NS Age of Majority Act (CanLII 1990), the minors become adults at age 19, with no stipulated age of consent for medical treatment. Under the NS Personal Directives Act (CanLII 2010), which replaced the Medical Consent Act, any person who has the capacity to make a personal care decision (i.e., is able to understand relevant information and appreciate reasonably foreseeable consequences) may make a personal directive. However, a substitute decision-maker (SDM) must be age of majority unless the SDM is a spouse or partner, in which case there is no age requirement. Under the NS Children and Family Services Act (CanLII 2020), children age 16–18 inclusive can contract with the agency for services.

By contrast, under Ontario’s Age of Majority and Accountability Act (ILO 2014), the age of majority is 18 years, again with no stipulation as to age of consent for treatment. However, under the Health Care Consent Act (Ontario 2021a), all persons are presumed to be capable of making treatment decisions, and under the Substitute Decisions Act (Ontario 2021b), persons 16 and over are capable of giving or refusing consent in connection with their own care, unless there are reasonable grounds to believe otherwise. The Health Care Consent Act recognizes an individual’s wishes, which may be expressed in a power of attorney or another written form, orally, or in any other manner, and SDMs must be at least 16 years old, unless they are parents of an incapable patient. Similarly, SDMs under the Substitute Decisions Act must be at least 16 years old.

Parents or guardians are the usual decision-makers for minors, but under both the common law and various statutory regimes, as minors mature, more weight is given to their wishes. Those assessed to be mature minors can make decisions that override those of their parents or guardian (Supreme Court of Canada 2009). In the health care context, where a court determines that a minor is sufficiently mature to understand the nature of the treatment and the consequences of accepting and refusing it, the court will permit the minor to make the decision despite the objections of parents, guardians, or care providers, though it will still consider the child’s best interests under its parens patriae jurisdiction. While it might be unusual for a court to extend autonomous decision-making to a child under 14–15, there is no hard threshold and all cases are context dependent (In CMG v. DWS 2015 ONSC 2201, the court rejected a parenting agreement in which disputing parents refused vaccination for their 10-year-old child and set the age of 12 for the child to make her own decision. Considering the child’s best interests, the court ordered vaccination and ordered that the vaccine-refusing mother was not to communicate with the child in a manner that would be negative to the child receiving vaccinations. In Re Calgary health Region 2006 CanLII 80851 (OIPC), the Commissioner gave effect to the 15.5-year-old’s refusal to release her medical records to her mother.). It has been suggested that the threshold for making decisions to accept vaccination contrary to parents’ wishes may be lower than for other more complicated medical interventions like surgery because of the reduced risk of vaccination (Glauser 2019).

For adults who are incompetent because of age-related progressive cognitive diseases, mental health problems, learning disabilities, brain injuries, etc., different legislation is implicated. For example, in Nova Scotia, the Adult Capacity and Decision-making Act (CanLII 2019), which replaced the Incompetent Persons Act, stipulates that another person can be assigned to make important decisions for an individual on matters affected by their incapacity. For a list of general factors to consider in relation to COVID-19 vaccination decisions, see Table 2.

All health care providers and immunization program managers must remember that all Canadians have the right to equality, equal opportunity, fair treatment, and an environment free of discrimination (McElhaney and Andrew 2021). Automatically deferring to a substitute decision-maker when the person does indeed have decision-making ability or allowing people to miss the opportunity to be vaccinated due to access issues are two examples of potential human rights violations in the delivery of COVID-19 vaccines in Canada.

As the most ambitious vaccination program in Canadian history ramps up, there will be occasions when individuals will experience an AEFI to the COVID-19 vaccines. Many of these will be mild and of no great consequence. However, there is the potential for very rare serious AEFI that leads to a negative outcome such as disability or death, such as the very rare but serious thrombosis with thrombocytopenia adverse events noted above. While there is no evidence that a vaccine injury support program in place leads to increased vaccine acceptance, this is the right time to consider a national program given that such programs have a an equitable and ethical rational given that immunization benefits the community not just the individual.

How should we handle those occasions when a person is harmed by a recommended vaccine taken in furtherance of the public good?

For those outside of Québec, the costs associated with a permanent or debilitating injury that is causally related to vaccination are currently borne by the injured individual (and their family), either personally as out-of-pocket expenses or through the purchase of private insurance or by the actors who bear some responsibility for the injury (e.g., vaccine manufacturers, administering health care providers, etc.) through tort litigation. However, access to these options is dependent on the individual’s social and economic conditions and capabilities. And tort litigation imposes a range of additional personal costs, including delay of benefits, financial cost, evidentiary hurdles, and emotional toll.

Surely, the concerns and sense of solidarity that drove Québec in the late 1980s to adopt its no-fault vaccine injury compensation program are shared across Canada. Canada announced in December a no-fault vaccine injury support program (VISP) to compensate and assist these individuals (Public Health Agency of Canada 2020). How this is implemented is critical. What should such a VISP look like? The seven characteristics that are essential to the fair, transparent and efficient operation of a modern VISP (Harmon 2021a) are noted in Table 3.

Given that COVID-19 pandemic has curtailed attendance at many activities and limited travel, the rollout of effective COVID-19 vaccines has raised the issue of COVID-19 vaccine certificates (Oguamanam 2021). This is not a new concept. The WHO-approved international certificates of vaccination or prophylaxis (ICVP), the yellow card, has been widely used since 2007 for documentation of immunization against diseases that are limited in geographical spread such as yellow fever (WHO 2021j). While there are points in its favour for documenting COVID-19 immunization (Flood and Thomas 2021) such as decreasing risk by not allowing those not immunized to participate in certain activities such as air travel, in-door restaurant dining, or work opportunities in high-risk settings, concerns have been raised that such certificates might be easily falsified, can create a false sense of security as COVID-19 vaccines do not prevent infection with all variants of concern (WHO 2021k), could increase health and social inequities, and are a distraction to even discuss at this point in the pandemic (WHO 2021l). There is no evidence to date that these would be an incentive for COVID-19 vaccine acceptance as it has not been studied. There is concern that the attraction would be of benefit only for those contemplating travel or indoor dining, i.e., the relatively elite. The legal and ethical defensibility of vaccination certificates is contingent on ensuring equitable access to the vaccine as well as the merit of having these, i.e., impact on COVID-19 disease transmission. The Royal Society of Canada Working Group on Vaccine Acceptance did not see this as a major incentive to consider for improving vaccine acceptance at this time; however, this might become more relevant for consideration as the COVID-19 vaccines rollout moved beyond the older age cohorts.

With respect to mandating COVID-19 vaccines, a number of factors would need to be in place before such an action could even be contemplated (MacDonald et al. 2018; Harmon 2021b). Views toward government mandating COVID-19 vaccines have been surveyed, with support for them falling from July to September 2020 (IPSOS 2020). However, while governments may for a variety of reasons decline to mandate, there remains the possibility driven by the desire of businesses to quickly return to full operational status—that employers may turn to mandates in relation to their employees. This begs the question: Should or can private enterprises stipulate COVID-19 vaccination as a condition of continued employment? If an employer is considering mandates, then it must be circumspect in doing so because employees forced to accept a vaccine or vacate the workplace could launch actions under the Charter (if the employer were a government actor), file complaints of discrimination under human rights legislation, or file labour grievances through their union if a collective agreement is breached. The example of mandated vaccination in the workplace has been addressed in Section 3.5.1.

These arbitrary decisions noted do not negate the validity of mandates but rather speak to the fact that mandates should have some scientific basis (re: effectiveness of the mandated action) and should not be contrary to already agreed working conditions.

A much more beneficial approach for employers—particularly large employers or employers in critical sectors (e.g., health care, social care, transport and shipping, education, etc.)—is to actively partner with public health authorities in the delivery of vaccines, helping to ensure ease of access as well as ease of obtaining necessary information to make the vaccination decision. There are a number of strategies that can help such as support positive vaccine decision-making (Harmon 2021b) (Table 4)

Eleven COVID-19 vaccines have been authorized or are in review (as of 14 April 2021) by the WHO following unprecedented collaborations made possible by a world threatened by the SARS-CoV2 virus (WHO 2021h). Canada has approved four of these under its priority review process as of April 2021; Pfizer-BioNTech’s BNT162b2, Moderna’s mRNA-1273, AstraZeneca-Oxford’s ChAdOx 1, and the Johnson & Johnson’s (Jannsen) AD26.CoV2.S. All have terms and conditions (Government of Canada 2021c) attached, signalling they can be quickly withdrawn should there be serious AEFI. Surveillance of their safety and effectiveness has received a funding boost by the Public Health Agency of Canada (,) and Canadian Institutes of Health Research (CIHR) (Government of Canada 2021h; CIRN 2021a; CIRN 2021b) along with efforts to return capacity for international disease surveillance (Robertson 2021) and national biomanufacturing (McQuaig 2020; The Globe and Mail 2021).

Discordance between jurisdictions within an institution is very problematic because policy change is hard. Persons working and living in federal correctional institutions share many factors that increase the probability of spread of COVID-19 if introduced and more serious illness amongst inmates due to the high prevalence of underlying conditions (RSC 2021). Outbreaks in correctional facilities have raised much concern and fear in the communities around them. Access to COVID-19 vaccine is problematic—prisoners in federal institutions are covered by a federal program, but the correction officers fall under the province in which the institution is located. This means incoherence in vaccine rollout; prisoners being offered vaccine but not the correction officers is undermining trust in the vaccines on both sides (R. Ricardelli, personal communication, 8 March 2021). Furthermore, there is no scientific rationale to support such a disjointed disconnect on access (see examples below).

Migrant workers both coming to Canada and within Canada provide more examples of jurisdictional disconnects. Neither are being coherently managed based upon scientific risk assessment and potential impact on communities. In the first COVID-19 wave in Ontario, 12% of migrant agricultural workers were infected after arriving in Canada and three died (Faraday et al. 2021). These are essential service workers that help ensure our food supply yet currently, Canada, neither federally nor provincially, has a coherent integrated plan for access to COVID-19 immunization for these migrant food workers (Faraday et al. 2021).

Workers in the oil sands in Alberta, many of whom are rotational migrant workers inside Canada, have also seen significant COVID-19 infections and even deaths (McDermott 2021). This is not surprising giving the congregate living at many sites. Many of these rotational workers have homes and families in other parts of Canada that they return to every month. This increases the risk of spreading COVID-19 to other communities and importing it as well when they return. As yet, there is currently no coherent interprovincial vaccine access program for these rotational workers nor for their families. Neither migration to Canada for an essential service nor migration within Canada count for vaccine access priority even if the risks of disease are higher and the potential impact on communities increased.

As noted in Section 2 there are many factors that influence vaccine acceptance including COVID-19 vaccine acceptance. Many of these factors are under the control of the health care program. For example, ease of access matters—where clinics are set up, who can come, distance to travel, cost for parking, hours of operation, etc. all influence attendance and acceptance. Currently many COVID-19 clinics have been set up to fit the system—initial concerns regarding transport of vaccine or plans for mass program. Little, if any, attention has been paid to working collaboratively with the communities these are intended to serve to ensure they fit the communities needs not just the programs. How will those with mobility problems manage, what about those that are blind, hearing impaired, and (or) have limited language skills in English or French. For example, almost three-quarters of all persons over 80 years in Ontario as of 23 March 2021 had been immunized or had appointments but nearly 200,000 had not signed up (CBC 2021b). Not surprisingly, the major issues identified included: reluctance among some seniors to go to mass-vaccination sites for their vaccinations, either because of transportation or mobility issues or because they fear it will increase their contact with others and therefore their risk of contracting the virus; limited opportunity to get vaccinated by their family doctor; language, literacy, and technological barriers to booking a vaccination appointment; lingering concerns about the efficacy rate of the AstraZeneca-Oxford vaccine and reluctance to take it because of initial guidance from NACI that it should not be used for adults 65 and older; and vaccine hesitancy, in particular among seniors worried about interaction with their prescribed medications. The program needs to address these issues but not blame or shame those who have not as yet come forward.

As noted in Section 3.2.1 programs need to be tailored to fit the group being served or low vaccine uptake will be the outcome (e.g., adult homeless example (Ghosh et al. 2021b)). Who attends and how attendees and are welcomed matters. Accepting a COVID-19 vaccine depends on trust—in the vaccine, in the immunizer, and in the immunization program. Immunization ambassadors from the community, those who actively champion vaccine, may be very helpful in garnering trust and in encouraging potential vaccinees to come forward (Habersaat and Jackson 2020). The experience must be as positive as possible (Taddio 2021) to ensure return for the second dose which may now be months later.

For many groups, bureaucracy must be minimized. Requiring a computer or phone to set up an appointment is a step too far for many equity deserving groups. Similarly, as noted above policies must not preclude access to vaccine because paperwork is missing—no health card, no identification etc. Even in rural remote parts of Afghanistan and Pakistan amongst populations who are illiterate, receipt of polio vaccine is checked with a blue dipped finger not by a note in a computer. The immunization program set up must be stretchable enough to serve all and not be the barrier.

All steps in the program need to be scrutinized through yet another lens. Is it needed or simply tradition? Using an alcohol swab to “cleanse” the area pre-injection is one example of an unnecessary procedure (Pakes and Taddio 2021). This not only does not add value for infection prevention, the smell can be off putting for some and these swabs cost money and add to medical waste and resources (time/personnel) for vaccination that could be deployed to improve access. Remember literally the COVID-19 vaccine program will likely swab over 70,000,000 arms if two doses of vaccine are needed.

A major gap in our current immunization programs and in health care across Canada is data (Ling 2021). We lack a fully integrated patient-centred electronic health information in all provinces and territories. Hence, knowing who should be prioritized because of underlying conditions is unknown at the provincial level. Such a system would also better support detection of serious AEFI and vaccine failures (MacDonald et al. 2020). Our current piecemeal system is not helpful at all and is impeding quality public health and acute, chronic, and preventive health care. While implementation of such systems takes time, COVID-19 can be the impetus. Such systems can improve health outcomes as well as decreasing costs if program management is built in (Graven et al. 2013). We cannot afford to ignore this data gap.

In the context of immunization clinics, prescreening vaccine recipients well before entering the clinic (and, if they are not well, asking them to return only when they are well again) serves as a form of local elimination.

Considerable attention has been placed on ventilation systems when people are indoors, and meeting outside has been recommended when possible. While immunization clinics cannot necessarily be outdoors, they should in large rooms or drive-through facilities that provide space for physical distancing and capacity for adequate ventilation both while the vaccine is administered and during the post-immunization observation period. Ideally traffic should be unidirectional.

Carefully documented policies and procedures should include checklists of the IPAC measures implemented at each site. It is also necessary to have a system in place that screens and tracks both immunizers and immunized, so if an inadvertent exposure occurs, individuals can be quickly notified.

In a medical setting PPE is designed to protect the wearer, and individual users put on and take off their PPE (such as masks, face shields, gowns, and gloves) when encountering a potentially contagious patient. It is essential that this is done properly to avoid the possibility of self-contamination. In the context of the pandemic, masking has become an important measure in protecting others, so immunization clinics must have adequate supplies for both the health care providers and those who present for immunization but do not have their own (Comeau 2021).

The American Centers for Disease Control (CDC) has developed comprehensive advice for those providing COVID-19 immunization. This guidance holds true in the Canadian context (CDC 2021c). Of note, while it may seem contradictory to infection prevention, however, the common but unnecessary practice of using an alcohol swab on the arm prior to injecting the vaccine is not advised because it can increase anxiety for some and does not have medical evidence to support its need for infection prevention (Pakes and Taddio 2021).

Policy makers and program managers need to ensure that the immunization delivery sites are following these best practices and have the required equipment to do this. Health care workers need to adhere to best practices and address concerns of those who are anxious. The safety of attending a COVID-19 vaccine clinic needs to be emphasized.

Concerns about words used in discussing vaccines and those reluctant to accept a vaccine have been raised pre-COVID-19 (Dudley et al. 2020). Words can dramatically affect how a message about COVID-19 vaccines is heard, how an invitation to be vaccinated is received, and the decision to accept or not. Labels may also over simplify complex dynamics and not lead to changes needed (Walcott 2020), and they may also obscure the impact of history and lives lived on the vaccine acceptance decision (Section 3.2.1). The Royal Society of Canada Working Group on COVID-19 Vaccine Acceptance has contemplated the words issue, discussing potential alternatives for terms that may be perceived as disrespectful, disparaging, and off putting in communication materials and discussions with individuals as well as words used when immunizing a patient (McMurtry et al. 2021). Such words add yet another barrier to vaccine acceptance. Table 6 presents some of these terms with potential alternatives. The list is not exhaustive but a start for those developing communication plans and materials for the public and for health workers interacting with the public about COVID-19 and COVID-19 vaccines .

In the spring of 2020, the WHO declared an “infodemic” was accompanying the COVID-19 pandemic (WHO 2021f). An onslaught of harmful, inaccurate information now pollutes the information ecosystem, causing confusion, stoking division in communities, and undermining public health messaging (Kurasawa 2020; Abdul-Mageed 2021; Swire-Thompson and Lazar 2021). As an example, Twitter exploded with COVID-19 tweets in 2020 (Abdul-Mageed 2021). Both COVID-19 vaccine misinformation (Scheufele and Krause 2019) (unintentional inaccuracies) and disinformation (Scheufele and Krause 2019) (deliberately false or misleading content) have been spreading rapidly and widely (Ryerson University 2021). Strategies to combat this have been outlined by WHO (2021g) and include timely dissemination of accurate information based upon science and evidence to all communities, particularly those at high risk and steps to prevent the spread of mis/disinformation education. Educate the public to recognize techniques being used. Public health and service providers must make it easier for lay people to find accurate information and check rumours for truth, providing opportunities for the public to query public health experts on confusing topics and enacting legislation to require better control accuracy of information on social media etc. (MacDonald 2020). All those recognizing COVID-19 online misinformation and disinformation are also encouraged to report this to the social media platforms so they can take action can address these (WHO 2021d). Sometimes even well-intended interventions by recognized institutions can contribute to the infodemic by adding to the confusion (MacDonald 2021). WHO has provided step by step guidance on how to report (MacDonald 2021).

The key to successful public communication to address factors affecting vaccine acceptance lies in careful targeting of messages about vaccine effectiveness, safety, and availability. This requires attention to 12 points of communication strategy (Table 7):

As noted above, the COVID-19 infodemic is overwhelming—not only for the public but also for health care workers. There is growing recognition that in terms of COVID-19 vaccine information tailored for a targeted subgroup using the above strategies, all within the subgroup are not looking for the same amount of information. Some want just a brief answer to the query—the bites—others want the bite plus some explanation—the snack—and still others want this plus the evidence—full lunch. This applies across the spectrum from one on one patient interactions with health care workers to public health materials for the public and (or) health care worker consumption. This means as evidence is prepared, the sources need to be referenced and where possible linked for those who want more than a bit or snack. Trustworthy evidence websites need to be highlighted. The WHO Vaccine Safety Net (VSN) helps Internet users find reliable vaccine safety information tailored to their needs (WHO 2021c). There are many VSN-approved websites in Canada in English and in French.

In the midst the cacophony of mis/disinformation, public health and health care worker messages must stand out as being consistent, accurate (i.e., evidence based), and up to date. Telling the truth, noting that the science has evolved, and this is what the new findings mean, must shine through the messaging. Correcting mis/disinformation is crucial. In the past concerns were raised that correcting a myth might make the myth stick even more. Recent research has shown that debunking the myth and presenting the correct evidence-based facts is helpful (Lewandowsky et al. 2020). While the Debunking Handbook was developed by experts from 20 universities (Australia, Canada, Germany, United Kingdom and the United States) to address climate change misinformation, the principles apply to addressing vaccine mis/disinformation as well (Lewandowsky et al. 2021).