Act before it’s too late

IT IS TIME FOR THE PROVINCES AND FEDERAL GOVERNMENT TO USE THEIR AUTHORITY TO MANDATE AN ITALY/SPAIN-TYPE SHUTDOWN

Canada and the rest of the world are now in the early phases of what will likely be the worst pandemic of acute respiratory infections in 100 years. No other pandemic infectious disease, with the possible exception of human immunodeficiency virus-associated AIDS, will likely have had as much of an impact on global human health and welfare as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2)-associated COVID-19 disease during this period.

At this time, the virus and its attendant severe acute viral pneumonia is rapidly racing through the populations of countries around the world. National health systems are being strained to their breaking points. Reports indicate that intensive care units (ICUs) in China, Italy and Spain are being overwhelmed with patients, to the point that painful decisions regarding triage are required. Similar, anecdotal, unverified reports are emerging from other parts of the world.

There are two factors that will determine the severity of the epidemic on a national level. First are mitigation strategies that include personal hygiene (frequent hand washing, efforts to disinfect contact surfaces), rigorous quarantine of potentially infected persons and social distancing. If implemented successfully, these efforts will result in a flattening and rightward shift of the epidemic curve. While a similar number of people may still get sick in total, the peak of the epidemic will be later and the number of patients requiring hospitalization and ICU care at the epidemic’s peak and throughout its course will be smaller. In short, while people will still get sick, there will be fewer of them at any given time. The cost of this intervention may be that the epidemic lasts longer, but the trade-off in lives saved by minimizing any overburden of ICU and hospital capacity is clearly worthwhile. When your loved one goes to the hospital with severe shortness of breath, the chance that an ICU bed and mechanical ventilator to sustain his or her life will be available can be increased substantially.

The other factor that will come into play is our healthcare resource capacity. Hospitals in Canada typically operate at 90 to 95 per cent capacity at the best of times. This year’s influenza season stressed ICU capacity beyond the standard bed availability and staffing levels in many hospitals. Additional ICU beds were temporarily opened with, where necessary, forced overtime for nursing and other support staff. In some cases, ICU bed capacity had to be increased by up to 25 per cent. This approach to open a limited number of ICU beds can be sustained for brief periods of time, but is not viable for what is coming.

Plans to augment ICU bed availability were developed and implemented during the 2009 H1N1 pandemic. Elective surgeries can be cancelled, which will make surgical ICU beds available. Consequently, post-operative recovery room beds, nurses and other support staff can be reassigned to handle coronavirus cases. Similarly, unused operating rooms can usually support ventilators and ICU equipment. Some hospitals have older ICU areas that are no longer in clinical use. These may be rapidly refitted, potentially with modest effort. The number of available ventilators can also be increased by utilizing simpler models used in the operating room, as well in-home support and patient transport programs. In addition, federal government emergency stockpiles can be utilized. ICU staffing, which our H1N1 experience has shown can be a critical bottleneck, can be augmented by reassigning and recalling hospital nurses and other staff with critical care experience. Under dire circumstances, inactive, retired and other professional staff now working outside the hospital environment could be asked to provide service. All these efforts could potentially increase ICU bed capacity by 100 to 150 per cent. It may still not be enough. Despite all this, there is a distinct possibility that ICU and hospital capacity could be exceeded by a substantial amount in four to six weeks.

There are other, perhaps difficult, ways that our country can and should respond to this dire public health crisis. Apart from a few places like South Korea and Singapore, affected countries have mandated the toughest, most disruptive social distancing measures only when the evidence for their need was clear. The problem is that once the need is clear, it is already too late. This can be seen most clearly in the efforts of the national governments of China, Italy and Spain. In each case, those difficult measures were not implemented soon enough to avoid destabilizing stresses on the health-care system. Patients in these places appear to be dying because the necessary support is unavailable. Their capacity to care for critically ill patients has been breached and triage for the precious commodity of ICU beds and ventilators is the only remaining option.

Canada is, at the moment, in an enviable position. We have time. However, this situation will not last long. There are currently less than 450 patients who have been identified with COVID-19 (the condition caused by SARS-CoV 2), only a handful are reported to be in ICU and just five have died. Published data indicates that we are just beginning the explosive, exponential growth phase of the national epidemic. Individual provinces, municipalities and institutions have implemented some social distancing measures, such as the banning of large gatherings, suspension of grade school and university classes and, in some cases, the closure of childcare facilities, public libraries and community centres. The federal government has urged Canadians to reconsider the use of public transport during the pandemic.

However, we can and should do more to arrest the exponential phase of epidemic growth while we can. Because the incubation period for infection (the time from virus exposure to apparent symptoms) is up to 14 days, our current case burden (number of cases) was determined up to two weeks ago when there were less than 20 known COVID-19 patients in the country. If the limited mitigation measures now being used are not effective, two weeks from now we are likely to have more than 3,000 known cases, with an unknown number of additional cases within the community. One to two weeks after that, we could have the Italian scenario. This will occur even if we implement more aggressive measures two weeks from now, since the impact of those public-health interventions will not impact the epidemic curve for up to two weeks after those more aggressive measures are implemented (i.e., more than one month from now)

It is time for the provinces and federal government to use their authority to mandate an Italy/Spain-type shutdown. This includes closing all schools, restaurants, bars, as well as non-essential services and businesses (excepting only medical facilities, pharmacies, grocery stores and emergency services). Of course, basic needs such as health, food, water, heating, shelter and safety must be maintained. Canadians should be asked to restrict themselves to their homes as much as possible, with exceptions for employment that does not allow remote work, food and supply shopping and providing assistance to the elderly and disabled. Of course, any person with suspected or proven COVID-19, or who’s at a high risk of being exposed to an infected person, must undergo mandatory quarantine. The government has just announced restrictions on travel to Canada by non-residents and even on the return of Canadians already exhibiting symptoms. Together, these measures should sufficiently slow the epidemic’s progress to a point where we can pursue other avenues to mitigate the impending surge of patients that may well overwhelm ICU and hospital capacity.

One such avenue that should be considered is the sharing of health-care resources (ventilators, etc.), and perhaps even staff, across jurisdictions. The developing epidemic curve is less a single curve for the entire country than cumulative outbreak curves for individual cities and towns. Within a city or town, epidemic diseases of this sort usually spread over a four to six week period, much like influenza, with a peak in the mid-period. A national curve has a similar profile, but may extend over more than three to six months without mitigation efforts. At some point in the middle of the curve, the number of towns and cities around the country experiencing their outbreaks is at the maximum. This causes the peak in the national curve. However, the local outbreaks are likely to be spread out in time and space. For example, Red Deer, Alta., and Montreal may be hit early, followed by Vancouver, Hamilton, Ont., and Winnipeg

a month or more later, and Toronto and St. John’s, N.L., a month after that.

If this is correct, we would have the opportunity to dynamically transfer resources from one area to another, depending on disease activity. However, this can only work if there is strong, centralized control of the movement of these resources (ventilators and potentially staff) between centres. This would, of course, also require real-time, national data on patient demand and resource deployment, as well as transport mechanisms (perhaps military) to move resources as required. This could potentially substantially increase Canada’s ability to respond to periods of very heavy local resource demand quickly, while ensuring that hospitals in low disease activity regions that have provided equipment or staff can have those resources replaced when their disease activity increases. While this approach could be effective in greatly augmenting local capacity for limited periods of time, this sharing of equipment would require either a compact between co-operating provinces, or the federalization of the effort, perhaps through a federal emergency declaration.

Canadian residents are at the cusp of what could become a historical event. The highest obligation of our political leaders is the protection of the residents of this country, which is home to us all. To do this, they must learn from the experiences of those who have suffered this pandemic before us. China, Italy, Iran and Spain, among others, show us what can occur if aggressive measures are not implemented in a timely way. South Korea and Singapore show what an early, assertive response to the threat can produce. If Canada is to avoid the fate of Italy, Spain and others, we must use the time gifted to us effectively. Our decisions in the next few days will determine the course of this epidemic in Canada. Panic and defeatism are not productive. Reasoned reassurance with an appropriate response is required. We hope that our leaders understand the challenges and risks before us.

WE HAVE TIME. HOWEVER, THIS SITUATION WILL NOT LASTLONG.

CANADIAN RESIDENTS ARE AT THE CUSP OF WHAT COULD BECOME A HISTORICAL EVENT.

Anand Kumar, MD, professor of medicine, medical microbiology and pharmacology, sections of critical care medicine and infectious diseases, University of Manitoba, and staff intensivist, Health Sciences Centre and

Grace Hospital, Winnipeg Salman Qureshi, MD, associate professor of medicine, critical care program and division of respirology, McGill University

Health Centre, Montreal Steve Reynolds, MD, FRCPC, clinical assistant professor, department of critical care medicine, University of British Columbia, assistant professor, department of biophysiology and kinesiology, Simon Fraser

University, TB vets chair in critical care research and medical director and staff intensivist, Royal Columbian Hospital,

New Westminster, B.C. R. Bruce Light, MD, FRCPC, professor of medicine, sections of critical care medicine and infectious diseases, University of Manitoba, and staff infectious diseases and critical care medicine staff, St. Boniface Hospital,

Winnipeg

Wendy Sligl, MD, M.Sc., FRCPC, professor, critical care medicine and infectious diseases, University of Alberta, Edmonton Angela Bates, MD, FRCPC, associate clinical professor of pediatrics, University of Alberta,

and intensivist, Stollery Children’s Hospital, Edmonton

Don Burke, MD, associate professor of clinical medicine, University of British Columbia, and staff intensivist, Abbotsford Regional Hospital, Abbotsford,

B.C.

Brian Minnema, MD, FRCPC, lecturer, department of medicine, University of Toronto, and ICU and infectious diseases staff, North York General

Hospital, Toronto

James Joshua Douglas, MD, clinical instructor, department of medicine, University of British Columbia, and staff physician,

critical care medicine and infectious diseases, Lions Gate Hospital, West Vancouver, B.C. Neeraj Verma, MD, assistant professor of pediatrics, Dalhousie University, Halifax Geoffrey Shumilak, MD, FRCPC, associate clinical professor of medicine, divisions of adult infectious diseases and critical care medicine, University of Saskatchewan, Saskatoon Vikas P. Chaubey, MDCM, FRCPC, clinical assistant professor, University of British Columbia, and critical care medicine consultant, Kelowna General Hospital, Kelowna, B.C. Gloria Vasquez-Grande, MD, staff intensivist, Winnipeg Regional Health Authority, and clinical instructor, department of medicine and PhD candidate in medical microbiology, University of Manitoba,

Winnipeg

Sylvain Lother, MD, chief fellow, section of critical care medicine, University of Manitoba,

Winnipeg

Ari Joffe, MD, FRCPC, clinical professor of pediatrics, division of pediatric critical care, University of Alberta and Stollery Children’s Hospital,

Edmonton

JUSTIN TANG / THE CANADIAN PRESS Medical staff work at a computer terminal on Friday as they prepare for the opening of the COVID-19 Assessment Centre at an arena in Ottawa where people can be assessed and tested for COVID-19 if required. This column was written by a group of health-care professionals who represent most of the Canadian physicians trained in both infectious diseases and critical care medicine. They are members of the Critical Care - Infectious Diseases Network, Canada and they include: