Hi John,

Can you please site the evidence that the vaccination of an individual actually decreases the transmission of disease or variant of disease to another individual. 

You did state in the article as though a vaccinated individual is decreasing risk for an individual in close proximity to them.  This is where I question that statement.

My understanding of the initial research although a lot more data is coming out with regards to those becoming infected after vaccination and also transmitting the disease after vaccination.  Regardless the original statement from Pfizer anyway was that it decreases severity of symptoms.  They did not state that it decreased transmission, hospitalization or death. And in fact now the government agencies are even stating that the vaccinated can get the disease and give the disease and now wanting individuals to consider a 'booster'.  If you have evidence to the contrary ie. showing that the COVID vaccine injection decreases transmission please site your sources. 

Even public health should be asked to disclose their data for their statements as they need to be held to a high level of accountability in this tricky situation.  And the propaganda can clearly blow things out of proportion in to the realm of lawlessness.  I hope the College will be very clear on the evidence behind their own statements and those coming from Public Health as well.

 

Justin,

There is no “strongest form” of evidence for these topics. Emerging evidence by definition indicates that the initial pictures are only beginning to become understood. Meta-analyses, for example, occur years later when statistics from different publications can be compiled. 

It is advisable for physiotherapists to always have reputable sources when discussing healthcare science. And, since it is very difficult for anyone to keep up on emerging science, especially when that science is tangential to one’s primary area of practice, it is helpful to have not just good sources but also good curators or sources. As a result, I would recommend that physiotherapists turn to sources such as Nature, one of the top 3 scientific journals in the world, and Scientific. Please see the following key links:

Nature News: https://www.nature.com/nature/articles?type=news (This isn’t entire about SARS-CoV2 and COVD-19 but you will find a lot of excellent and relevant information here.)

Coronapod – Nature’s Weekly Pandemic Report: https://podcasts.apple.com/gb/podcast/coronapod-ivermectin-what-the-science-says/id81934659?i=1000531263799

Covid, Quickly, A Pop-Up Podcast – Scientific American’s COVID-19 podcast, which is published every two weeks: https://www.scientificamerican.com/article/covid-quickly-a-pop-up-podcast/

Here is a Nature article speaking to Justin’s question about references: “How do vaccinated people spread Delta? What the science says” Available at: https://www.nature.com/articles/d41586-021-02187-1

Some of the key points from this article are:

1. “When early field data showed that vaccinating people cuts transmission of the SARS-CoV-2 virus, researchers were cautiously optimistic. But they warned that many of those studies, although promising, took place before the fast-spreading Delta variant proliferated worldwide.”

2. “Delta is more likely than other variants to spread through vaccinated people.”

3. “Data from COVID-19 tests in the United States, the United Kingdom and Singapore are showing that vaccinated people who become infected with Delta SARS-CoV-2 can carry as much virus in their nose as do unvaccinated people.” Please note, that if vaccinated people are not sick or less sick and not, for example, coughing and sneezing then the same viral load may not equate to the same R0 (“R naught”).

4. “However, vaccinated people with Delta might remain infectious for a shorter period, according to researchers in Singapore who tracked viral loads for each day of COVID-19 infection among people who had and hadn’t been vaccinated. Delta viral loads were similar for both groups for the first week of infection, but dropped quickly after day 7 in vaccinated people.”

5. “The results suggested that among people testing positive, those who had been vaccinated had a lower viral load on average than did unvaccinated people.”

Because Nature is a reputable source, you can find scientific references at the end of their report, a link to which is provided above.

Hi Karen,

Thank you for your post!

I wanted to ask you about a statement that you made, because I would love to have your cited reference since you were very good at placing references except for your last statement:

 
"In addition, overall risk of being infected with COVID in a vaccinated individual is far less that unvaccinated. Takeaway is that the risk of an unvaccinated individual transmitting COVID is decreased compared to an unvaccinated individual. This research is in early stages however and we need more data. Hope that helps clear up any misunderstandings."

You forgot to place a reference for this statement. Is this your personal opinion, or do you have a reference for a clinical trial or meta-analysis/systematic review that supports this statement? You mentioned that this "research is in its early stages" it sounds like you have reference for this? Do you have a peer-reviewed journal article that supports this statement or is this what you heard/read on the news? If this is on the Public Health website did you manage to find the strongest form of evidence which would support this statement?

Just want to correct some of the confusion/misinformation in these comments below:

1. As an advanced practice PT in spine, there is no mechanism by which a vaccination would cause a radiculopathy. If this was observed it is likely a correlation (coincidental timing), and does not prove causation.

2. Which brings me to my 2nd point: VAERS is used for pharmacovigilance, and anyone can enter in an event as a potential side effect meaning this information is unverified and subject to inaccuracies & bias. Correlation does not equate causation.

To access VAERS, you have to click that you have read & understood the following disclaimer to access this data: "VAERS reports alone cannot be used to determine if a vaccine caused or contributed to an adverse event or illness. The reports may contain information that is incomplete, inaccurate, coincidental, or unverifiable. In large part, reports to VAERS are voluntary, which means they are subject to biases. This creates specific limitations on how the data can be used scientifically. Data from VAERS reports should always be interpreted with these limitations in mind." 

Therefore VAERS should never be used as confirmation of vaccine side effects unless published or investigated by the CDC who has put out a statement (e.g. about the VITT). 

3. Preprint (not yet peer reviewed) research from Singapore shows vaccinated individuals can have high viral load, potentially comparable to unvaccinated, however this declines much more rapidly in vaccinated due shorter duration of illness.  https://www.medrxiv.org/content/10.1101/2021.07.28.21261295v1?%25253fcollection=

Another preprint study from UK found viral loads in vaccinated individuals have lower viral loads than unvax.  https://spiral.imperial.ac.uk/bitstream/10044/1/90800/2/react1_r13_final_preprint_final.pdf

In addition, overall risk of being infected with COVID in a vaccinated individual is far less that unvaccinated. Takeaway is that the risk of an unvaccinated individual transmitting COVID is decreased compared to an unvaccinated individual. This research is in early stages however and we need more data. Hope that helps clear up any misunderstandings.

Hi Stephen,

The role of the College during the pandemic is to share updates and information from the Ministry of Health with physiotherapists and other stakeholders. The MOH has released this guidance for all primary care providers and not physiotherapists specifically, although much of the content is applicable to physiotherapists in community settings. As noted in the highlighted comment, the MOH encourages providers to discuss and offer the COVID vaccination “where possible and appropriate.” As vaccinations are outside the scope of practice for physiotherapy, this direction does not necessarily extend to physiotherapists.

One thing I really find interesting is that the college recently uploaded an update on July 29, 2021 for primary health health care providers in community settings.

If you open it and scroll down you will notice the following advice

"Primary  care  providers should  consider  discussions of  vaccine  status with patients  and, where  possible  and  appropriate, offer  COVID-19  vaccinations."

Why does the college allow physiotherapists to speak about their private medical information and begin discussions which can be observed as clinical opinions about a matter that is out of their scope of practice?

 

Thank you

 

"The second comment highlighted by John speaks to treatment of a patient who has disclosed that they are not vaccinated and the potential for physiotherapists to employ additional screening measures or precautions, if supported by scientific evidence and Public Health Guidance at the time. As of right now, physiotherapists must continue to follow all measures detailed in the College’s Return to Work guidance for all patients."

In other words, all patients are to be treated equally in terms of precautionary measures. Both vaccinated and unvaccinated patients in terms of pre-screening, sanitary measures, mask, eye protection since transmission is possible in both vaccinated and unvaccinated and therefore this not change precautionary measures to prevent viral transmission to/from patient/physiotherapist.

Thank you for your clarification

Wanting to know a healthcare provider's vaccination status is potentially not just about issues related to potential transmission of SARS-CoV-2. For example, we purport to work in an evidence-based profession, which should mean that we keep up to date on scientific evidence and abide by it when working in the clinic. It is certainly true that much of the evidence in our profession is open to interpretation but the available evidence on the vaccine is far more specific and much less open to interpretation. As a result, it is completely plausible that a patient would justifiably not want to work with an unvaccinated healthcare professional. If that professional isn't following expert advice on vaccination then maybe they also aren't following other forms of expert advice within their area of clinical practice. Whether or not a healthcare professional is vaccinated could imply not only that they are not up to date on healthcare science but also that they don't take the risk of getting COVID-19 seriously, which could in turn indicate that they are less likely to implement other public health recommendations that could keep them and their patients safe. While I have seen no scientific evidence regarding these particular variables, it is completely understandable if a patient decides to not work with a physiotherapist that is not vaccinated.

Nicole, there is also a long history of orthopaedic manual therapy research related to the interactions of manual therapy and the autonomic nervous system (ANS). This is very important during COVID-times because the human body’s immune response is partially controlled by the ANS. Not only have vaccinations been repeatedly and consistently correlated with a temporarily increased risk of autonomic dysfunction, but the physiotherapy profession has long been used to help manage ANS symptoms. In fact, the ANS has been shown to play a minor or major role in a wide range of conditions including but not limited to: dysautonomia, POTS, T4 syndrome, diabetes, osteoporosis, RA, OA, chronic lower back pain, tendinopathy, ACL injury, acute surgical pain, Parkinson disease, spinal cord injury, MS, stroke, COPD, myocardial infarction, and sepsis. Why is this so important for physios? Well, if the vaccination (or an illness) can promote an ANS response and the ANS is linked to all of these relevant physio topics then it is 100% reasonable to expect that some patients with these conditions will have an exacerbation of their non-vaccine symptoms in the days/weeks after receiving the vaccination. I have seen this over and over again and my patients find it very helpful when I educate them about what the relevant research says. By educating patients about published scientific findings I am often able to decrease catastrophizing, which is an important way for physios to help control pain and other relevant variables. Stated otherwise, vaccine status cannot be separated from a thorough physiotherapy examination and management strategy.

Hi Miriam,  

Thanks for your comment. To further clarify, the first comment highlighted by John is in regards to physiotherapists advising patients regarding vaccines. This is not within the scope of practice for physiotherapy. As such, physiotherapists may choose to disclose their vaccination status however, as noted in the blog, they should not make comments to patients about the efficacy or use of vaccines, such as the PT cannot transmit COVID-19 because they are vaccinated. A statement that individuals who are fully vaccinated cannot transmit the virus to others is outside the practice of physiotherapy and not currently supported by public health information.  

The second comment highlighted by John speaks to treatment of a patient who has disclosed that they are not vaccinated and the potential for physiotherapists to employ additional screening measures or precautions, if supported by scientific evidence and Public Health Guidance at the time. As of right now, physiotherapists must continue to follow all measures detailed in the College’s Return to Work guidance for all patients.

Vaccinated status does not mean that vaccinated practitioner is safer practitioner than one who is not vaccinated. Your suggestion that we should disclose our vaccination status to provide reassurance to patients implies that we should provide the patient false sense of security when in fact The current evidence is that vaccination protects only the person who is vaccinated (as it decreases the symptoms) and not in any way anyone else. Especially due to new variants constantly emerging. So providing our personal health information should not be suggested by the College in order not to contribute to misleading the public, especially during these very sensitive times.

Regarding, "When can a PT ask a patient about their vaccination status? A patient should only be asked questions about their health status if it is relevant to their care.” Isn't all health related information relevant to all healthcare providers? We, for example, take thorough health histories on every patient we see so that we can properly and thoroughly understand their health status. No information is out of bounds and we can't determine any information's relevance until after we hear the information. Additionally, we have been required to ask every patient COVID-19 related questions at every visit over the last year and the vaccine question is the most relevant COVID-19 question. As a result, it seems like there is never a time when the vaccine question is irrelevant to clinical practice as a physiotherapist. So, based on this information, can more clarity be provided when it might be or would be inappropriate to ask a patient if they are vaccinated? I certainly can't imagine any scenario in which that information is not in some way or another related to practicing as a regulated healthcare provider. Thank you.

Hi Nicole,

Thanks for your comment. As part of your assessment and gathering of subjective information, it is good practice to ask the patient if anything has changed since the last time you saw them, or if there is anything impacting their health that could influence your approach to treatment.

Hello,

I believe John's question above deserves an open written response for everyone to see. That would be in my opinion an expected part of an open discussion.  A question asked in a polite and professional way deserves an answer.

We can all learn from a dialogue.

Thank you.

 

 

Considering the adverse reactions post vaccination that have been reported through VAERS including blood clots, Bell's palsy, neurological issues, it seems to be in the patient's best interest that the physiotherapist inquires about recent vaccination when taking patient's history. I assessed patients that developed radiculopathy, had acute episode of sciatica, had an enlarged calf with a negative Homan's Test to name a few. All these happened within 2-7 days post vaccination and were always on the side of the inoculation. 

All these do come under physiotherapist's expertise and differential diagnosis is important. 

 

Hi John  

Thanks for your question. Please contact the Practice Advice team and they would be happy to provide further clarification. They can be reached at 1-800-583-5885 (extension 241) or by email at advice@collegept.org.

"Further, a statement that because you are vaccinated there is no chance that you can transmit COVID-19 to patients would not be supported by public health information available at the time of writing."

 

"However, exceptions might exist where the best, recent scientific evidence is that physiotherapists should employ additional precautions (beyond usual screening and universal precautions) for unvaccinated clients."

 

The college is contradicting itself, in the second statement, it is suggesting that the vaccination status of the pt will affect transmissibility of the virus and that PT should take additional precautionary measures if they are unvaccinated.

 

Please explain,

 

Thank you