From real-time data to PPE , health officials weren’t ready
What went wrong? What can Canada do to fix it before the next wave hits? A detailed look at Canada’s delayed response to the coronavirus outbreak.
The Canadian economy is cautiously reopening, new COVID-19 cases are declining steadily and public health officials were finally able to enjoy a moment of relaxation over the Victoria Day long weekend.
With the pandemic’s first wave almost behind us, now experts are surveying the damage and looking for lessons.
It’s not just an academic exercise, either, with epidemiologists warning that the virus will likely be circulating around the globe until a vaccine is developed.
If Canada is determined not to make the same mistakes again, the hard part won’t be coming up with recommendations, it will be summoning the political will to plunge resources into fixing the problems.
In fact, many of the most important recommendations were already made in a report commissioned after the 2003 SARS epidemic. Medical experts mention it with a sense of frustration, but also hope the current crisis will inject much-needed urgency into the situation.
A study by the Center for Infectious Disease Research and Policy at the University of Minnesota outlined three scenarios for the coming months and years: multiple “peaks and valleys,” a massive peak in the fall, or a slow burn without a major resurgence.
Any of those scenarios will require improvements to areas that didn’t live up to expectations when COVID-19 came to Canada.
“I think a big lesson we’re learning is that we have to continue to pay huge attention to public health and maintain adequate funding. That SARS commission report was prescient. It almost predicted everything," said Sandy Buchman, president of the Canadian Medical Association.
Because it oversees the National Emergency Strategic Stockpile and Canada’s health data, the Public Health Agency of Canada has drawn criticism for shortages of personal protective equipment and the data blind spots about the disease, but there were failure points at just about every level on issues vital to keeping the COVID-19 pandemic at bay.
THE STOCKPILE DEBACLE
When the COVID-19 outbreak in Canada is studied for mistakes and missteps, the grim sight of two million expired N95 respirator masks and 400,000 pairs of expired medical gloves being destroyed will be at the top of the list.
In a matter of months, personal protective equipment, or PPE, has gone from an obscure acronym to everyday vocabulary.
“We didn’t stockpile sufficient PPE and that’s why we’ve been scrambling. I think the government’s been doing a remarkable job in trying to procure and create a domestic supply of PPE by retooling manufacturing facilities for that but we were caught flat-footed," said Buchman.
The government should have been monitoring the equipment in the stockpile and then shipping it out to hospitals when it approached the expiration date, said Buchman.
It’s the kind of job that requires little more than a spreadsheet or one very vigilant person monitoring it.
“It’s not rocket science, for sure," said Buchman. "And the expenses … in procurement retooling are probably far greater than it would have cost to keep up the supply of quality equipment because now we’ve also run into the problem of substandard equipment being imported and a lack of domestic supply,” he said.
The failure in supply of personal protective equipment is made even more frustrating because the SARS report warned against this very problem.
During the SARS outbreak, health- care workers were directed to wear fit- tested N95 masks, which added layers of extra protection to fight the epidemic. The fit-test is a cumbersome procedure that involves each worker trying a series of different designs while a bitter- tasting gas is sprayed at them.
Health- care workers also wondered why they needed to wear respirator masks when SARS was spread by droplets and not airborne particles. Surgical masks, which were given to patients and visitors at hospitals, would have trapped the droplets and helped prevent transmission.
In response, the SARS commission recommended that the National Emergency Strategic Stockpile take on a sourcing and clearinghouse function, rather than just building a stockpile where medical gear sits for years.
That would make for a more dynamic system that was buying gear for the crisis at hand rather than ones in the past. The medical equipment that was destroyed last year, for example, had expired in 2014.
That’s exactly how Alberta built its stockpile and it meant health-care workers in that province went into the outbreak with three to four months of medical supplies on hand, rather than mere weeks worth of gear available in some other provinces.
“Say, for example, every week, I need a million gloves, right? Basically my teams will draw from the stockpile and then a purchase order will bring the item back into the stockpile,” said Jitendra Prasad, Alberta’s chief program officer for contracts and supply management contracts. “So the stockpile is constantly rotated and refreshed, so that you never end up in a situation where things expire.”
There are two huge benefits to this. First, nothing is sitting idle in the stockpile for very long, except for highly specific gear that isn’t in general use. Second, the central authority in the province is accustomed to sourcing materials from different manufacturers because it is constantly buying gear for health workers throughout the province. When smaller disasters crop up around the world, the procurement team has to be nimble and deal with supply issues, which can work almost like a dry run for a larger disaster like a pandemic.
If other provinces are looking to the Alberta model for inspiration, Prasad said to focus on getting clean data at a central location. “At the end of the day, if you don’t have that visibility, you could have a situation in a pandemic where there is a particular hospital that has lots of stock. But there could be a hospital right down the street that actually has no stock. In the two hospitals, if they’re buying separately, they’re actually competing for the same availability,” said Prasad.
FIXING CANADA’S DATA
Every day Canadians get a blast of COVID-19 data from public health officials across the country. Each province releases its own statistics, in its own format: positive cases, number of deaths, number of recovered cases, number of tests. To get an accurate picture of where the country stands as a whole, one has to collate all the numbers. That doesn’t add up.
Many of us have developed an unlikely fixation on the number of positive cases of COVID-19, deaths resulting from the disease and the growth or decline in cases, because they are the metrics that will allow us to reopen our economy, see our loved ones, determine if it’s safe to venture out.
A Statistics Canada report on “excess deaths” released last week, illustrated some of the limitations on the data we’re collecting. For one, it doesn’t include Ontario, where more than one- third of Canadians live, and where more than 20,000 people have tested positive for COVID-19.
Meanwhile, the United States and other countries are pushing almost real-time data on excess deaths, which is one of the key insights into the severity of the COVID-19 outbreak. It’s a gap that Statistics Canada is scrambling to fill, but reliable data is a problem that has failure points at every level.
Information about a person’s death is slow to be processed and there’s no good way to link it with other data, said Laura Rosella, an associate professor of epidemiology at the University of Toronto’s Dalla Lana School of Public Health.
People studying deaths in Canada have to piece together a disjointed chain of information — from an ER visit, to residency at a long-term care centre, to an appointment at a family doctor or a positive test for COVID-19.
“That’s impossible in real- time because of the way our system is so fragmented," said Rosella.
Rosella said in the short term, as the country prepares for a possible second wave of COVID-19, Canada could follow the example of the United States.
“What you do is you set up a real- time death reporting system, so that they have interim numbers, and they report them as such," said Rosella. The numbers won’t be perfect and would likely be revised when the authorities comb through them, but it would give policymakers something to work with in the meantime.
During a fast- moving health-care crisis like a pandemic, where public health officials are tackling a virus that could be spreading exponentially, data needs to flow quickly.
“We have to make decisions very quickly. And if we are accepting the fact that because we don’t have data quickly and we’re making our quick decisions without data, then that’s a problem,” said Rosella.