PANDEMIC LESSONS
What we learned will help us prep for next wave
The winds were light, the winter clouds thickening, when a 56-year-old man was taken by paramedics to a Toronto hospital in the late afternoon of Jan. 23.
He was feverish, with a dry, hacking cough, symptoms that had grown worse since returning home a day earlier from Wuhan, China, where a peculiar viral pneumonia of unknown origin was circulating.
He was immediately placed in a private room that had the appropriate air handling. Emergency staff at Sunnybrook Health Sciences Centre scrupulously followed procedures and protocols developed since SARS for dealing with a potential novel “high consequence” pathogen, donning long-sleeved gowns, gloves, N95 respirators and face shields. While he seemed relatively stable, almost as if he little more than a common cold, his chest X-ray was starkly abnormal. There were changes down in the lower parts of the lung, opacities in all of the different lung zones, and when infectious diseases specialist Dr. Jerome Leis saw the images for the first time he remembers thinking, “This must be that novel coronavirus being described in Wuhan.”
Today, 16 weeks after Leis looked at those cloud-like, fluffy patches on the lungs of Canada’s patient zero, the first imported case of what would later be called COVID-19 to arrive on Canada’s shores, we’re still grasping for words to describe what we’ve been through — and what may still come.
It’s too early to write a full post-mortem, though Prime Minister Justin Trudeau has promised a post-pandemic review once the crisis has passed.
“Are there things we could’ve done differently,” the PM said last week during his Rideau Cottage daily briefings. Certainly, he conceded, when it’s all said and done, “there will be people who will have recommendations. We will look at how we can better prepare for next time, if there is a next time.”
A next time seems as certain as the return of winter. There are already lessons to be learned from Canada’s response to COVID-19, as well as a four- to five-month lead before the anticipated rebound, the resurgence, the feared second wave hits to act upon them.
From a canvas of experts in critical care, infectious diseases, epidemiology, family medicine, public health law, nursing and emergency medicine, and testimony transcripts from the House of Commons health committee studying Canada’s response to the pandemic, there were failings.
Chief among them, that Canada was slow to recognize the magnitude of the threat posed by an unsentimental virus. Canadian health officials continued to stress the risk to Canadians was low into the second week of March, even though many scientists were saying otherwise and nervously eyeing the carnage unfolding in Italy. Ontario Premier Doug Ford told families to “go away, have a good time, enjoy yourself” on March Break. Travel restrictions came late. The country’s largest province lost control of the testing to look for the genetic footprint of the virus in cells swabbed from the back of noses. There were unacceptable testing backlogs, critical shortages of swabs and key ingredients.
And, after decades-long neglect of emergency rooms, it was too late for hospitals to suddenly build surge capacity for COVID-19 patients.
On Jan. 15, Canada activated its emergency operations centre. On Jan. 29, Dr. Theresa Tam, Canada’s chief public health officer, told MPS on the health committee it was possible that asymptomatic persons could spread the virus, but that it would be “rare, and very unlikely” they would be the key drivers of any actual outbreak or epidemic. On Feb. 1, the World Health Organization’s situational report stated the agency was aware of the possibility people were spreading the virus before showing symptoms. Four days later, Tam, appearing before the health committee again, said the case reports out of China hadn’t been verified or substantiated. NDP Vancouver East MP Jenny Kwan asked, had we contacted China directly for clarification? Tam responded that, ‘It’s actually quite a difficult piece of epidemiology to ascertain whether some asymptomatic person could ever transmit.” It’s when someone is coughing vigorously, when they’re more symptomatic, “that, we believe, this virus is transmitted.”
While other countries closed borders, Canada posted messages on arrival screens, added screening questions on electronic kiosks at Toronto, Montreal and Vancouver airports and handed out pamphlets requesting returning travellers inform border services officers if they were feeling flu-ish and to self-monitor for symptoms. For asymptomatic people, Canada’s health leaders said, there was no evidence yet we should be quarantining them. It took until the third week of March for Canada to finally close its borders to all non-essential travel, including to the United States.
Border measures are only one layer of the response to a frightening new pathogen. The other is a once-unimaginable shutdown of public life. But that misstep allowed the virus to gain a foothold, experts say. “Canada’s initial lack of a robust border policy or mandated supervised quarantine program for both incoming travellers and contacts of documented cases has impaired our ability to contain the epidemic here,” Peter Phillips, a clinical professor medicine in the division of infectious diseases at the University of British Columbia, wrote in the Canadian Medical Association Journal. The early response trailed the evidence. It wasn’t until the end of March that Canada began enforcing 14-day quarantines for any person entering Canada by air, sea or land, whether or not they had symptoms of COVID-19. On April 7, Tam tweeted that studies from several countries had now demonstrated pre-symptomatic virus spread was, indeed, occurring, and more often than previously thought.
“In retrospect, we could have closed the USA border earlier, and restricted all incoming flights to Canada to a handful of airports earlier, descending upon those airports with overwhelming public health powers,” including mandatory testing and quarantining of all travellers from China and Europe, University of Ottawa global health epidemiologist Raywat Deonandan wrote in an email. Preventing people from going abroad for March break also could have helped.
To free up hospital beds for COVID-19 patients, thousands of scheduled surgeries were shelved at the end of
March. We emphasized ICU units and ventilator capacity and forced the infections out to the community — into understaffed long-term care homes, where underpaid and unprotected staff worked at multiple homes to cobble together a living. Across Canada, roughly 80 per cent of COVID-19 deaths have been linked to longterm care.
As April arrived, the nation witnessed a frenzy of panicked buying to secure an adequate supply of personal protective equipment (PPE) for frontline healthcare workers. Planes sent to China arrived empty. Others delivered a million contaminated masks and defective swabs. A hospital in Toronto launched a public appeal for unused and unexpired PPE. Emergency room staff in Hamilton hospitals were instructed to keep wearing their first surgical mask “until grossly soiled or wet,” an edict Linda Silas, president of the Canadian Nurses’ Association described as “sick. It goes against all our training in disease prevention,” Silas told MPS in the first week of April.
Meantime, as the virus took hold around the world, the messaging from Canada’s leaders fumbled. Stayat-home orders and restrictions on public gatherings varied from province to province. Emergency doctors described disorderly and fuzzy communication from all levels of government — confusion about who to test, when to test, who to admit, who to send home. From media reports and exhausted colleagues in the trenches in Italy and New York, doctors and nurses could see what was coming, and prepared for the worst. “It really seemed to many of us on the ground that we were on our own,” says Dr. Alan Drummond, of the Canadian Association of Emergency Physicians.
There were moments of “do as I say, not as I do.” Ontario Premier Doug Ford visited his Muskoka cottage on Easter Sunday to check the plumbing after appealing to Ontarians to stay home. Trudeau crossed the river into Quebec over Easter to visit his family at Harrington Lake, the official country home of the prime minister, posing with his wife, Sophie Gregoire Trudeau, and their children, for a cheery Instagram selfie after telling Canadians, “This long weekend, we all have to stay home.”
Dr. Ross Upshur doesn’t think there is a health-care system anywhere on the planet that was prepared for COVID-19. We stumbled by mischaracterizing the threat, says Upshur, a family physician and head of the division of clinical public health at the Dalla Lana School of Public Health. “It wasn’t until we saw the kind of carnage evolving in Italy that the actual threat became clear.”
China has a younger, less “multi-morbid” population than Italy, and Canada looks more like Italy than China. “What COVID has taught us that we already knew is that we had a population that was particularly vulnerable to the ravages of this disease,” Upshur says, meaning we remain vulnerable for the foreseeable future, largely because multi-morbidity — underlying health problems like obesity and high blood pressure — is the rule, not the exception. For the virus hasn’t gone away. It’s still circulating. As of this week, Canada had more than 72,000 confirmed cases. The true number may be 10 times the official count, which would still leave just under 37 million “susceptibles.”
It’s easy to look back and point the finger of blame. But there were also bright spots. Canada’s response wasn’t flawless, but neither was it America’s, where the chief executive was contemptuous of medical evidence, motivated mainly by getting people back to work, safe or not, and eager to grab the first “miracle” cure — malaria drugs, bright light, bleach. In Canada, the decision to socially distance, and the public’s “magnificent” response to adapt, bought time for hospitals to prepare, Drummond says. As the pandemic evolved, as the virus began showing some of its cards, public health measures were added.
Each death has been an “incalculable tragedy,” Tam told MPS in early May, the pandemic “the most challenging and shape-shifting event in our collective careers.” The provinces that reacted sooner to keep infections down, like British Columbia and Alberta, lessened excess deaths. The epidemic growth is slowing; there’s a levelling of the trajectories across most jurisdictions in Canada. Our total case counts are increasing more slowly than most countries.
What do we need going forward? A massive investment in human health resources in public health. “Even if you have an app, it’s not going to do all the work. You need feet on the ground, good old-fashioned shoe leather epidemiology and contact tracing,” says Upshur. The army of post-secondary students receiving monthly stimulus cheques could be recruited into a COVID public-health peace corps and trained to do contact tracing, identifying those who have come into contact with people infected with the virus. Testing, rapid contact tracing and surveillance will be crucial to identify clusters, new flare-ups of infections.
“When a fire is flaming everywhere, you aim the hose everywhere,” says Dr. Alan Burnstein, president and CEO of CIFAR, a Canadian-based global charitable organization. “Towards the end you aim it where you think there are still hot embers. That’s what we need to do.” Timing is everything. Every moment after someone is infected and they aren’t quarantined is an opportunity to infect others.
Canada needs a guaranteed supply chain for PPE, drugs and ventilators. The days of hospitals with 120 per cent bed occupancy have to end, Drummond says. There are concerns that as hospitals begin tackling surgery backlogs, they could become overloaded again, unable to withstand a substantial second wave. We need to focus on the vulnerable first, and integrate long-term care facilities into an overall strategy. And as restrictions are relaxed, we need to evaluate which ones were most effective.
The best-case scenario is we start to release some of the restrictions and we don’t see a resurgence of disease, Upshur says. But we need to be prudent.
“We need to be prepared to walk back as we walk forward, because nobody can say with any certainty how this is going to play out.”
YOU NEED FEET ON THE GROUND, GOOD OLD-FASHIONED SHOE-LEATHER EPIDEMIOLOGY