Testing fractional doses of COVID-19 vaccines.

Due to the enormous economic, health, and social costs of the COVID-19 pandemic, there are high expected social returns to investing in parallel in multiple approaches to accelerating vaccination. We argue there are high expected social returns to investigating the scope for lowering the dosage of some COVID-19 vaccines. While existing evidence is not dispositive, available clinical data on the immunogenicity of lower doses combined with evidence of a high correlation between neutralizing antibody response and vaccine efficacy suggests that half or even quarter doses of some vaccines could generate high levels of protection, particularly against severe disease and death, while potentially expanding supply by 450 million to 1.55 billion doses per month, based on supply projections for 2021. An epidemiological model suggests that, even if fractional doses are less effective than standard doses, vaccinating more people faster could substantially reduce total infections and deaths. The costs of further testing alternative doses are much lower than the expected public health and economic benefits. However, commercial incentives to generate evidence on fractional dosing are weak, suggesting that testing may not occur without public investment. Governments could support either experimental or observational evaluations of fractional dosing, for either primary or booster shots. Discussions with researchers and government officials in multiple countries where vaccines are scarce suggests strong interest in these approaches.

The Syndemic of Inequity and COVID-19 in Virtual Care.

The critical intersections of structural inequities and vulnerabilities of marginalized populations, particularly those engaging the social gradient of minority ethnic communities, are revealed in the syndemic approach to COVID-19. Although proposals for cultural interventions to improve virtual care provide relevant measures, they may not address the root cause of the disparate impacts of a pandemic on population subgroups. The common misperception of equality as synonymous with equity further impedes the efficacy of digital health in quality-of-care initiatives, as it systemically fails to acknowledge the disparate realities of marginalized populations, while intending to benefit all. This commentary suggests that an alignment of the health care system with Canada's pluralist principles would support a paradigm shift in transforming virtual care into an equitable standard as envisioned by Pham and colleagues in their paper, "The Future of Virtual Care for Older Ethnic Adults Beyond the COVID-19 Pandemic."

Patients as Front-Line Owners and Partners in Improving Quality and Safety.

As patient partners, we are pleased by the success of the front-line ownership (FLO) approach in advancing safe care in a variety of initiatives and settings. The FLO underlying principles and approach deeply resonate with us as illustrated in the following quotes from the paper: "Nothing about me without me," "Most passionate change agents are not in roles that typically get invited to participate," "Inviting anybody who is interested in the problem at hand," "FLO creates a way to break down hierarchies, increase positive dialogue between diverse players in organizations, and encourage people who may not have felt empowered previously to come forward and problem-solve." It is not described in the article if and how patients and/or patient partners were involved; therefore, we call on the authors to follow up with that information because it can provide valuable lessons to others who will be looking at implementing FLO in their organizations. Based on our decade-long experience as patient partners at all system levels, on literature and leading practices (key references included) we argue that patients have an important role to play in improvement initiatives and recommend partnering with patients in all improvement efforts.