Persius/hicric huggingface dataset:
Archived 47: Summary of National Advisory Committee on Immunization (NACI) updates of November 3, 2022: Recommendations on the use of Moderna Spikevax BA.4/5 bivalent mRNA (50 mcg) COVID-19 booster vaccine in adults
Overview
- On November 3, 2022, Health Canada authorized the use of the Moderna Spikevax 50 mcg BA.4/5 bivalent COVID-19 vaccine as a booster dose in individuals 18 years of age and older.
- Health Canada has previously authorized similar bivalent booster doses containing Omicron BA.1 or BA.4/5 variants from Moderna (50 mcg) and Pfizer-BioNTech (30 mcg) in September and October of 2022.
- Available evidence suggests this new Moderna bivalent BA.4/5 formulation is comparable to other bivalent booster products already authorized and recommended for use as part of the fall 2022 COVID-19 booster program.
- NACI continues to recommend that bivalent Omicron-containing mRNA COVID-19 vaccines are the preferred booster products for the authorized age groups. (Strong NACI recommendation)
- Going forward, any of the bivalent Omicron-containing mRNA boosters are preferred over the original formulation boosters for authorized age groups (18 years of age and older for Moderna bivalent vaccines and 12 years of age and older for Pfizer-BioNTech bivalent vaccines).
- Bivalent Omicron-containing mRNA vaccines are expected to broaden the immune response and provide improved protection against the Omicron variant and subvariants compared to original mRNA COVID-19 vaccines, with a similar safety profile.
- Omicron is the most distinct variant of concern to date, with a number of key mutations distinguishing it from the original SARS-CoV-2 virus. The BA.4 and BA.5 Omicron subvariants are currently the dominant strains of the COVID-19 virus circulating in Canada.
- Health Canada and NACI are currently reviewing whether bivalent vaccines may also be an option for boosters in children 5 to 11 years of age this fall.
- There is currently no evidence to suggest any meaningful difference in protection between different bivalent booster vaccines targeting BA.1 versus BA.4/5, nor any clinical trials directly comparing the Moderna (50 mcg) and Pfizer-BioNTech (30 mcg) bivalent booster products. Vaccine effectiveness has not yet been established for the bivalent booster products.
- COVID-19 booster doses this fall are an important part of the ongoing pandemic response, contact your local public health department to learn where you can receive one.
For more information on the authorization of this new bivalent booster formulation, please refer to the .
For more information on NACIs recommendations on the use of COVID-19 vaccines, please refer to the  in the , as well as additional statements on the .
Sexually transmitted and blood-borne infections: Guides for health professionals
The Public Health Agency of Canada (PHAC) provides public health guidance for the prevention and management of sexually transmitted and blood-borne infections (STBBI). PHAC's STBBI guides for healthcare providers and public health professionals outline national recommendations for:
- the screening and diagnosis of STBBI
- the treatment of sexually transmitted infections (STI) of national public health importance
These guides replace the Canadian Guidelines on Sexually Transmitted Infections. PHAC's STBBI guides do not supersede:
- provincial/territorial legislative, regulatory, policy and practice requirements
- any professional guidelines that govern the practise of health professionals in their respective jurisdictions, whose recommendations may differ due to local epidemiology or context
Treatment recommendations include indications for the .
Sexually transmitted and blood-borne infection guides
Find key information and public health guidance for the screening, diagnosis and treatment (if available) of:
Information on best practices for the prevention and management of STBBI:

# Updates to the Guide
National Advisory Committee on Sexually Transmitted and Blood-Borne Infections (NAC-STBBI)
PHAC's STBBI guidelines are developed in collaboration with an expert advisory committee with  from across Canada. .

# NAC-STBBI statements
Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 20222023
These testing guidelines are meant to provide guidance on recommendations for COVID-19 testing. This testing guidance does not replace the need for clinical judgment, which remains critical in determining whether a COVID-19 test should be offered to a patient. Health-care providers should also apply the principles of equity, cultural safety and humility, and consider contextual factors, such as access to health-care services, personal and community factors, and systemic racism.# 
A PCR test may be preferred in specific circumstances such as for variant surveillance. A PCR test is indicated for testing of patients in acute care settings.
Positive rapid antigen test (RAT) results are acceptable for initiating treatment and no confirmatory testing is required for outpatients. If a RAT is negative and clinical suspicion remains high, patients may repeat a RAT or clinicians can order PCR testing.

# Testing recommended by medical health officers in high-risk settings or as part of a public health investigation
Testing is indicated when it changes either individual or community management. Your local medical health officer may issue region-specific recommendations based on epidemiology, vaccination rates or access to health services.
Medical health officers may also recommend testing as part of public health investigations. This may include testing of asymptomatic people who are part of a public health investigation of a case, cluster or an outbreak.
Additional Guidance

# People who have symptoms compatible with COVID-19 who do not meet the above COVID-19 testing recommendations can use a rapid COVID-19 test.
This may be especially important for communities with difficulty accessing testing (and secondary or tertiary care) such as rural, remote, and isolated or Indigenous communities and work-camps, and for Indigenous people living in urban settings. For more information about point-of-care testing for rural, remote, First Nations and Indigenous Communities, please refer to the guidance on the BCCDC website.

# Additional guidance for children
All children who are suspected of having multisystem inflammatory syndrome (MIS-C) should also be tested. Infants less than three months of age who are febrile or who have suspected COVID-19 should be assessed by a health-care provider. For more information on the diagnosis and management of COVID-19, please refer to the BCCDC website.

# Testing for travel purposes
In B.C., testing is not available through the provincial health-care system for screening related to travel. The exception is people requiring testing for medically necessary travel (for example unvaccinated people requiring travel for medical reasons from remote communities).

# Additional guidance for health-care workers
PCR testing is no longer recommended for all health care workers, first responders, staff and residents in congregate settings unless they meet other criteria for testing. People with symptoms compatible of COVID-19 may use a RAT if they wish.

# Specimen Requirements
Please refer to the BCCDC Public Health Laboratory eLab Handbook under COVID-19 virus for specimen requirements
Can patients receive the Covid-19 vaccine if they are taking warfarin?# 
- We encourage patients who are receiving warfarin treatment to receive vaccinations, including the Covid-19 vaccine. - There is a small risk of bruising at the vaccination injection site, but we do not expect any serious effects related to being on blood thinning treatment. - We suggest that after the vaccine injection prolonged pressure for 3 to 5 minutes is applied to the injection site to reduce bruising. - There is no need to measure the blood thinning level (INR test) just before receiving a vaccination; you should continue INR testing according to the schedule recommended by your doctor.
Can patients receive the Covid-19 vaccine if they are taking a newer blood thinner, one of apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Lixiana), or rivaroxaban (Xarelto)?
- We encourage patients who are receiving blood thinning (anticoagulant) treatment to receive vaccinations, including the Covid-19 vaccine. - There is a small risk of bruising at the vaccination injection site, but we do not expect any serious effects related to being on blood thinning treatment. - We suggest that after the vaccine injection prolonged pressure for 3 to 5 minutes is applied to the injection site to reduce bruising.
Can patients receive the Covid-19 vaccine if they are receiving aspirin or a similar drug because of a previous heart attack or stroke?
- We encourage patients who are receiving aspirin or similar drugs like clopidogrel (Plavix) or ticagrelor (Brillinta) to receive vaccinations, including the Covid-19 vaccine. - There is a small risk of bruising at the vaccination injection site, but we do not expect any serious effects related to being on blood thinning treatment. - We suggest that after the vaccine injection prolonged pressure for 3 to 5 minutes is applied to the injection site to reduce bruising.
For additional questions e-mail us at info@thrombosiscanada.ca
- The document entitled Guidance for Surgery After COVID-19 Infection: Timing of Surgery Following Recovery from COVID-19 to Reduce Risk of Postoperative Mortality has been rescinded.
- This guidance document was developed in January 2022.
- It was based on pre-Omicron variant COVID-19 data. There is now more information available about how the Omicron sub-variants affect patients peri-operatively. - In addition, the patient population is generally more immune due to COVID-19 infection or vaccine or both.
- Clinicians should follow the American Society of Anesthesiologists (ASA) and Anesthesia Patient Safety Foundation (APSF) Joint Statement on Elective Surgery and Anesthesia for Patients after COVID-19 Infection when determining timing of surgery following recovery from COVID-19 infection in a shared decision-making model with the patient.
- It is hoped that there will be an update to this guidance that takes into account the effect of COVID-19 immunization status on patient surgical outcomes. - COVID-19 immunization status is one component of the risk assessment that should be done pre-operatively. This information may not always be available. - Therefore, it is up to the clinical team to use best judgement based on the available information. - However, procedures should not be delayed or cancelled based on COVID-19 immunization status alone.
Please contact:
- Surgery.SCN@ahs.ca for general questions about this provincial guidance.
- Site Surgery and/or Anesthesia leads for patient-or site-specific questions.
This guidance is intended for health-care providers responsible for newborn care. It is based on known evidence as of April 13, 2021.# Summary of Key Changes in This Update
The recommendations in this document were developed based on best available evidence and with input from Ontario Health's Evusheld Clinical Working Group.- There are limitations to the evidence that is currently available. Information about Evusheld, including its effectiveness against different variants of COVID-19, is evolving rapidly. Prescribers must determine whether adopting suggested information is clinically appropriate for individual patients through a risk-benefit assessment.Ontario Health does not recommend routine use of Evusheld for pre-exposure prophylaxis for any patient group, including immunocompromised patients, due to the prevalence of variants that are resistant to Evusheld (including BA.4.6, BF.7, BQ.1, and BQ.1.1), 1,2 which are expected to comprise >55% of circulating variants in Ontario by December 7, 2022. 3 The prevalence of variants that are resistant to Evusheld is expected to continue to rise given weekly relative growth rates. 3 Evusheld will remain available to be dispensed through pharmacies for use as pre-exposure prophylaxis in exceptional circumstances where the health care provider and patient have determined that the potential benefit outweighs the risks (e.g., with consideration to regional prevalence of resistant subvariants and individual patient risk factors). Any health care provider administering Evusheld due to exceptional circumstances (as outlined above) should refer to the product monograph 5 for details on Evusheld, including information on dosing (600 mg of Evusheld, administered as two separate 3.0 mL, sequential, injections of 300 mg of tixagevimab and 300 mg of cilgavimab) and repeat dosing (every 6 months).Health care providers should communicate with patients who have received Evusheld to: 4 - Inform patients about the potential for a lack of effectiveness against certain circulating variants and that if they have received Evusheld in the past, they cannot rely on it for protection.# 
- Advise patients of the importance of immunization as the best method to remain protected against COVID-19. - Advise patients to continue to limit potential exposure to COVID-19 through public health measures such as masking and limiting contacts. - Advise patients to immediately seek medical advice if signs or symptoms of COVID-19 occur. Ontario Health's Evusheld patient handout has been revised to support communications with patients as outlined above.

# Treatment
Ontario Health does not recommend use of Evusheld for treatment of COVID-19 due to the risk of treatment failure against currently circulating variants in Ontario 1,2,3 and the availability of more effective treatments (e.g., Paxlovid).
This document is intended for use by experienced clinicians, including prescribers and pharmacists. The information is not intended to replace sound professional judgment in individual situations, and should be used in conjunction with other reliable sources of information. Clinicians should always consider the risk/benefit profile for their individual patient, discuss these risks with the patient or caregiver before initiating therapy, and closely monitor for treatment benefit and adverse effects.# 
For questions about the reproduction, adaptation, translation, or other uses of this material, contact: phrcpd@uwaterloo.ca

# Financial contribution from:
It can be challenging to manage drug interactions between COVID-19 treatments and DOACs. Vaccination can reduce the risk of needing treatment for COVID-19.
People who take a DOAC should stay up to date with their COVID-19 vaccines, including boosters.
Funded by the Canadian Institutes of Health Research (CIHR), the Canadian Research Initiative in Substance Misuse (CRISM) is a national research-practice-policy network focused on substance use disorders, comprising four large interdisciplinary regional teams (Nodes) representing British Columbia, the Prairie Provinces, Ontario, and Quebec/Atlantic. Each CRISM node includes regional research scientists, service providers, policy makers, community leaders, and people with lived experience of substance use disorders. CRISM's mission is to translate the best scientific evidence into clinical practice, health services, and policy change. More information about CRISM can be found at:  document is one of a series of six national guidance documents, rapidly developed by the CRISM network at the request of the Government of Canada. Collectively, the six documents address urgent needs of people who use substances, service providers, and decision makers in relation to the COVID-19 pandemic. The urgent nature of this work required rapid development and dissemination of this guidance. This, and the continuing evolution of the knowledge base regarding COVID-19, precluded CRISM from conducting a comprehensive review of the relevant literature. However, when available, scientific evidence is cited in support of the expert advice offered herein.# 
The guidance provided in this document is subject to change as new information becomes available. Readers should note that the intent of this document is to provide general guidance rather than detailed procedural and logistical advice. Readers are advised to consult local public health and medical authorities for specific input on navigating their own unique regulatory and policy environments, as necessary.
The CRISM/COVID-19 guidance documents cover the following topics: - Strategies to Help Individuals Self-Isolate for People who use Drugs Each document was developed by a core CRISM regional authorship committee, drawing on expert knowledge, available scientific evidence, and a review of relevant documentation from public health authorities. Draft documents produced by each authorship committee were reviewed by pan-Canadian panels of content and clinical experts, including people with lived and living experience of substance use. A Directed Operating Grant provided funding for this work to CRISM from the Canadian Institutes of Health Research (CIHR).
As we progress toward an endemic phase of the COVID-19 pandemic, there is a need to re-evaluate which pandemic precautions should be maintained for performance of pulmonary function tests (PFT). Specifically, how should risk be mitigated for patients and health care workers as the dynamics of viral transmission evolve over time. This third update of the Resumption of PFTs in the era of COVID-19 presents the current evidence to support performance of PFT in dedicated laboratories and in primary care settings across Canada.
Throughout the pandemic, health care workers have been at increased risk of exposure to SARS-CoV-2. 1,2 Conversely, within Canada, there have been no reported cases of SARS-CoV-2 transmission in a PFT laboratory. This likely reflects the cautious approach applied by most PFT laboratories and that performing PFTs has been mainly limited to well ventilated spaces with high air exchange rates (AERs).
With nearly 75% of the Canadian population now fully vaccinated against SARS-CoV-2, 3 the risk of COVID-19 in healthcare settings, 4,5 as well as in the general population, is reduced but not eliminated. Vaccination is most effective at reducing severe illness and death, not virus transmission, and the duration of protection is uncertain. Community spread of SARS-CoV-2 continues in Canada as does uncertainty with respect to future risk as novel variants of concern emerge. Mandates for vaccination of health care workers vary across the country, and a large proportion of the population is still only partially vaccinated or unvaccinated (including children). Furthermore, there are patients (and health care workers) who remain at high risk of COVID-19 despite being fully vaccinated. The perception of risk varies between individuals, and those who attend PFTs need to feel safe and reassured that the level of risk in a PFT laboratory is low and that precautions are being taken to keep them safe.
Situation: Vaccine-induced immune thrombotic thrombocytopenia (VITT), also known as thrombosis with thrombocytopenia syndrome (TTS), is a rare, idiosyncratic life-threatening condition that can arise after COVID-19 vaccination with AstraZeneca (AZ) or Johnson & Johnson/Janssen (JJ) vaccines (not reported with Pfizer or Moderna vaccines). This document with supplemental appendices has been developed through extensive consultation with BC medical experts and physician groups to improve awareness and to help guide screening, diagnosis and management of VITT/TTS. Background: VITT/TTS is a condition characterized by: 1) symptom onset 4 to 28 days after exposure to AZ or JJ vaccine; 2) platelet count less than 150 x 10 9 /L; and 3) thrombosis, especially in uncommon sites such as cerebral venous sinuses and abdominal veins (eg. portal vein), as well as arterial thrombosis. Mortality is estimated to be approximately 20%. VITT/TTS resembles heparin-induced thrombocytopenia (HIT) in its mechanism, and diagnosis requires the presence of anti-PF4/heparin antibodies. Similar to HIT, early diagnosis is essential because patients can deteriorate rapidly. Currently, the recommended treatment is empiric initiation of intravenous immunoglobulin (IVIG) and a non-heparin anticoagulant. Based on available data, the best estimate of the risk of VITT/TTS after vaccination with AZ or JJ vaccines is 1 in 100,000 doses. In BC, approximately 400,000 doses of the AZ and JJ vaccines are anticipated to be administered, but this number may increase as our vaccination campaign continues.In an effort to best protect British Columbians, BC medical experts have put together 4 documents for dissemination to all physicians and other healthcare providers involved in patient care post-vaccination.# Primary Care Outpatient Assessment

# Assess for Risk
- Risk of VITT/TTS is 1 in 100,000
- Only AstraZeneca and Johnson & Johnson (Janssen) vaccines have been associated with VITT/TTS
- Symptoms occur 4 -28 days after vaccine (peak period 6 -14 days)
- VITT/TTS can occur in all ages and both sexes, but is most commonly reported in younger women
- Patients with history of blood clots are not more likely to have VITT/TTS

# Assess for Clotting
- Have a high index of suspicion, ask about all of the following:
-persistent and severe headache
Humira has been proven to be effective in a number of rheumatic and inflammatory diseases. Unfortunately, adherence to Humira injections is often limited by the associated pain reported by patients 1 . This is particularly challenging for young children. Painful injections impact negatively on the quality of life of children and their families. Studies have shown that 40% of children resist medications that involve injections, and parental fear of pain predicts a decrease in treatment adherence 2 . Citrate-free Humira is available to patients in the United States, Europe and many other countries worldwide. Studies have shown that this formulation causes significantly less pain 3,4 , thereby improving adherence and quality of life. Despite Health Canada approval, and for reasons that are not clear, citratefree Humira is not available in Canada. Thus Canadian children are being denied access to citrate-free Humira, which is better tolerated than the current formulation, despite availability of citrate-free Humira to patients elsewhere. The Canadian Rheumatology Association strongly recommends that access to citrate-free Humira be made available for Canadian children requiring treatment with Humira.