TOO MANY BLIND SPOTS
Had Canada acted swiftly at the start of the COVID-19 pandemic, and not squandered the health gains of the national lockdown this past spring, we could have been in a much different place with the pandemic today.
It took several months before Canada was convinced the novel coronavirus spread by stealth. Not only are we still paying the price for that delay, but a few super-spreaders are ignoring health officials' message. James Bagnall looks back at the federal response to COVID-19.
When the virus finally hit us, it turns out we were screening for the wrong things and looking the wrong way.
Worse, in the midst of a rush of new cases this autumn, too many of us continue to underestimate the SARS-CoV-2 virus, the pathogen that causes COVID-19. Because of this, our systems for testing and tracing have been overwhelmed.
The result, as this special report makes clear, is that we have consistently remained one or two steps behind in our war to tame the novel coronavirus.
Federal health authorities failed early on to draw the right conclusions about how the virus spreads, despite multiple pieces of evidence in plain view. More puzzling, they delayed putting into place common-sense policies, such as mandating the wearing of non-medical face masks.
This might have put a brake on the rapid early climb of COVID-19 infections, and the hospitalizations that resulted.
While we eventually got things on course, especially in the Atlantic region, the delay meant Canada's response has been middle of the pack in terms of success. We've been substantially better than the U.S. at reducing the caseload on hospitals and minimizing deaths per capita. But our record pales against that of New Zealand, Australia, South Korea, Vietnam, Taiwan and much of Scandinavia.
Many within the latter group have the good fortune to be geographically remote. But they had something else in common that proved critical in dealing with the pandemic: government leaders who were either trusted or feared, and public health experts who convinced them they had to move swiftly to restrict movement across their borders and lock down large parts of their economies.
Because they acted, the virus was denied free rein, allowing health authorities to hurl everything they had at tamping down the occasional fires. In sharp contrast, Canada is struggling with vast gaps in its knowledge of how the virus is spreading through the community. When outbreaks do occur, especially in central Canada's hotspots, governments have been forced into ham-fisted, region-wide lockdowns instead of targeted quarantines.
This is why so many of us are heading into winter in a dispiriting fog of uncertainty about how long we must endure this alternate reality. Had Canada acted swiftly at the start, and not squandered the health gains of that national lockdown this past spring, we would today be in a much different place.
Taiwan's Premier Su Tsengchang left little doubt about the scope of the health crisis about to unfold.
The island nation had just the day before — Jan. 22 — confirmed its first case of COVID-19.
Following a briefing by his country's top epidemiologists, Su declared that all national efforts aimed at preventing a COVID-19 epidemic “shall be considered combat mission.” Further, he urged, “all government agencies must rapidly respond.”
What he meant was more rapidly.
Practically from the moment local Chinese health officials acknowledged cases of pneumonia of unknown origin in late December, Taiwan had been doing on-board inspections of direct flights from Wuhan, the apparent epicentre of the virus outbreak. Suspicious it wasn't getting the full story, Taiwan also sent two of its most senior health experts to Wuhan on Jan. 13 for a firsthand appraisal.
They concluded human to human transmission of the virus couldn't be ruled out and held a press conference a few days later upon their return to Taiwan.
While it wouldn't become clear for weeks that the virus was being spread asymptomatically, Taiwan prepared for the worst. In so doing, it happened to put into place the strategies for combating such a scenario.
Among other measures, Taiwan distributed millions of surgical face masks to convenience stores and set in motion a plan to quadruple mask production. A small army of health workers was trained to track and trace the spread of the infection.
Taiwan's wartime posture would make all the difference in the weeks to come, and contrasted sharply with the far more deliberate approach adopted by most other countries, including Canada and the World Health Organization, the United Nations agency with responsibility for monitoring and responding to disease outbreaks.
The day Su issued his call to arms, Canada activated a government-wide COVID-19 operations centre in a small office complex on Laurier Avenue in downtown Ottawa. Although Canada would record its first confirmed case of COVID-19 on Jan. 25, a sense of national urgency would take nearly two months to manifest.
The numbers tell the story. By mid-October, Canada's COVID-19 case count had soared to more than 186,000 during the course of the pandemic, including nearly 9,700 deaths.
Confirmed cases over the same period in Taiwan, which has nearly two-thirds of Canada's population, totalled 529, including seven deaths.
The big puzzle, of course, is why Canada was so paralyzed by the approaching virus.
Much criticism has been levelled at the Liberals' underfunding of the Global Public Health Intelligence Network, a 23-year-old unit within the federal government's health agency that scours the globe's newspapers, blogs and government websites for signs of emerging health problems.
But in the case of COVID-19, early warning doesn't appear to have been the problem.
Hundreds of Canadian medical professionals and government health officials subscribe to FluTrackers.com and ProMED, publications that warned about the outbreak of a mysterious pneumonia in Wuhan on Dec. 31 and Dec. 30, respectively.
Toronto-based BlueDot, a private firm whose clients include the federal Foreign Affairs department and Health Canada, also picked up local media reports on Dec. 31 from China. BlueDot crunched data from mobile phones and airline passenger traffic to predict — accurately in many cases — where a potential epidemic might spread.
Company founder Dr. Kamran Khan forwarded a copy of his conclusions in early January to Chief Public Health Officer Theresa Tam who, on Jan. 6, emailed colleagues to note she was planning to run BlueDot's epidemic intelligence platform to model events in Wuhan.
They were aware of the virus and its likely initial path. What they didn't know was what was driving it. BlueDot noted Jan. 14 that the potential of human-to-human transmission of the virus was unclear.
In the Jan. 27 edition of Journal of Travel Medicine, the company wrote that a big unknown was how efficiently the virus was spreading from human to human. Whether people without symptoms were passing the virus on to others was not directly addressed.
“While our algorithms gather epidemic intelligence and anticipate how they are likely to spread,” Khan noted in an email to this newspaper, “we collect clinical information about new pathogens through the peer-reviewed scientific medical literature.”
The Public Health Agency of Canada, established in 2004 in the wake of the severe acute respiratory syndrome (SARS) epidemic,
considered the possibility of asymptomatic and pre-symptomatic spread from the beginning but took its time evaluating the scientific evidence. In response to queries by this newspaper, the agency said it conducted “rapid reviews” into this question in February, March, April and June “to brief on the new evidence as it evolved.”
PHAC said that by Feb. 26, it was aware of five publications that suggested pre-symptomatic transmission had occurred. By March 24, the agency noted there were 34 studies. “The evidence was starting to provide some parameters around how many days before infection can someone transmit SARS-CoV-2 and what proportion of infected cases never develop symptoms,” PHAC said.
Why so deliberate? In part, it was a question of previous experience. Key public health officials
in Canada and the World Health Organization initially viewed COVID-19 through a lens shaped by recent epidemics — H1N1 and SARS — and the coronaviruses that produced them. Indeed, the coronavirus that caused SARS shares 70 per cent of the genetic sequence of SARS-CoV-2.
“Early in the pandemic there was sparse data on SARS-CoV-2 and its transmission,” PHAC said. “At the time, knowledge of other viruses was being used to understand (its) possible attributes.”
This approach provided some initial comfort. During the nine months ended August 2003, an estimated 8,500 people worldwide were diagnosed with SARS. Nine hundred died. Canada, the most affected country outside of China, reported 438 probable cases and 41 deaths, most in the Toronto area. Sobering numbers, yes, but well short of what we're experiencing now.
“The models which seemed most similar to COVID-19, the original SARS and influenza, suggested that asymptomatic transmission would be unlikely,” McGill University infectious disease specialist Dr. Michael Libman told this newspaper, adding that China had been dealing with the COVID-19 outbreak for a month at that point and had not clearly identified symptomless spread as an issue.
“We know now that they were completely overwhelmed with the outbreak,” Libman noted, “and had no resources to properly study transmission.”
Because the earlier outbreaks involving SARS and H1N1 were spread mainly by people with obvious symptoms — cough, fever, and pneumonia — medical workers found it easier to isolate the viruses. COVID-19 is different. Canadian health officials missed two opportunities to draw a faster conclusion about the stealth qualities of this virus and its corollary, namely that physical distancing and face masks are the best way to keep it at bay until drug makers can produce a vaccine or cure.
Early clues were not just in plain sight, they were brought to the attention of senior health officials in the capital region. Canada as a consequence was left significantly more vulnerable to COVID-19 than it otherwise would have been.
Libman was one of the first to see it. A colleague — Dr. Camilla Rothe, who practices at Munich University Hospital — had co-authored a report published in the New England Journal of Medicine on Jan. 30. It was brief — just two pages long — but contained a stunning message.
It suggested COVID-19 could be spread by people who showed no symptoms.
“The fact that asymptomatic persons are potential sources of (coronavirus) infection,” Rothe concluded, “may warrant a reassessment of transmission dynamics of current outbreak.”
That was putting things mildly. “The disease will most likely eventually spread around the world,” Libman wrote Rothe in a Feb. 4 email after reading her report.
Libman's note, which he confirmed to this newspaper, had been a welcome voice of support for Rothe, who at the time was stunned by the amount of pushback she had received from researchers around the globe.
Rothe's paper examined Germany's first confirmed case of COVID-19, a 33-year-old employee in an auto parts company who had been in contact with a symptomless business colleague visiting from China. The controversy swirled around whether that colleague had actually been free of symptoms or whether they had been mild enough to avoid detection.
The Feb. 3 edition of the journal Science cast some doubt on Rothe's observations, citing concerns raised by a second group of German researchers. The next day, a top official with WHO, Dr. Sylvie Briand, tweeted a link to the Science article.
Tam weighed in. “With regard to the New England Journal study,” she testified before a House of Commons committee on Feb. 5, “there's now been a publication to say that it was incorrect and that this person was, in fact, symptomatic and had been taking some medication that suppressed his fever.
“That's a very important fact to verify and correct,” Tam continued. “I'm very happy that German scientists and WHO have verified that.”
But they hadn't. According to a report in The New York Times, Bavarian medical staff had been studying multiple cases of COVID-19 infection. They concluded in the second week of February that symptomless spread was the cause and forwarded their research to the WHO and the European Centre for Disease Prevention and Control.
“I had the advantage of knowing Dr. Rothe personally,” Libman noted, “and I knew how fastidious and careful she is.
“Certainly no one wanted to believe in asymptomatic transmission because that would indicate a problem that would be difficult to control,” Libman added. “Unfortunately, humans can tend to be biased against accepting ideas they fervently hope to be untrue.”
No one wanted to believe in asymptomatic transmission because that would indicate a problem that would be difficult to control.
As late as March 28, Tam was advising Canadians “there is no need to use a mask for well people.” Three days later, she changed her guidance by acknowledging that non-medical masks can help to stop the spread of COVID-19.
“WHO guidelines are one of many resources that inform Canada's guidance on non-medical masks,” PHAC responded on behalf of Tam. “We also closely follow the emerging scientific literature and the experiences of other jurisdictions.
“Evidence on pre-symptomatic and asymptomatic transmission led (us) to a (federal-provincial-territorial) consensus that wearing a non-medical mask was an additional measure that could be taken,” PHAC added.
March 28 was the same day Dr. Robert Redfield, director of the U.S. Centers for Disease Control and Prevention, noted that one in four infected people were transmitting the virus 48 hours before showing symptoms.
WHO scientists, however, were still cautious in early summer.
“Transmission of COVID-19 is occurring from people who are pre-symptomatic or symptomatic,” WHO noted in a scientific brief published July 9. “Transmission can also occur from people who are infected and remain asymptomatic, but the extent to which this occurs is not fully understood and requires further research as an urgent priority.”
But in the midst of a pandemic characterized by rapid spread, the key is equally fast containment and, when that fails, mitigation.
Canada had another timely opportunity to figure this out. And, once more, it missed the signals.
On Feb. 3, an 18-storey cruise ship with 2,666 passengers on board — 251 of them Canadian — prepared to dock at Yokohama, Japan. The Diamond Princess, in service since 2004, was nearing the end of a two-week cruise that had taken in the sights of China, Hong Kong and Taiwan.
The vessel was about to be transformed into a biology experiment that would shed much light on the reproductive power of the coronavirus.
Two days earlier, the Hong Kong government had warned that one of the ship's passengers — an 80-year-old male who had disembarked Jan. 25 in the former British colony — had tested positive for the coronavirus.
Japan, exercising caution, quarantined the ship and began testing passengers. Within 48 hours, the first 10 cases on board were confirmed.
By Feb. 23, nearly 700 had tested
positive, with roughly half of those people showing no symptoms, according to a study of the Diamond Princess outbreak published by the Society for Disaster Medicine and Public Health.
Epidemiologists and health officials were riveted. Dozens of U.S. government officials and independent researchers emailed each other regularly during February, their shock growing by the day.
“What happened on the cruise ship is a preview of what will happen when this virus makes its way to the U.S. healthcare system (not to mention institutionalized high-risk populations like nursing homes),” noted Dr. Carter E. Mecher, senior medical adviser for the U.S. Department of Veterans Affairs, in a very prescient Feb. 20 post. “I'm not sure that folks understand what is just over the horizon.”
Thirteen days earlier, when just 70 Diamond Princess passengers had been confirmed positive for COVID-19, Dr. Eva K. Lee, a researcher affiliated with Georgia Institute of Technology, was equally observant.
“This (outbreak) also reinforces the notion that social distancing has to begin now, not later,” Lee wrote in the same email string, which was obtained through Freedom of Information Act requests to local government officials by Kaiser Health News and The New York Times. “Testing capability remains critical,” Lee added. “But with limited testing ability, we better be smart in how to sample.”
The timing of Lee's email, Feb. 10, is significant. Canada had already ferried hundreds of nationals from China to the Canadian Forces base at Trenton, Ont., where they were being quarantined for two weeks.
Now Canadian military aircraft were preparing to escort Diamond Princess passengers to NAV CAN's facilities in Cornwall for a similar quarantine.
Internal emails by Patrick Tanguy, assistant deputy minister at Public Safety Canada, are revealing. In a Feb. 17 update to senior officials in multiple federal departments, he noted that 355 Diamond Princess passengers had already tested positive for COVID-19. Included in his email distribution list: Public Health Agency of Canada president Tina Namiesniowski and Chief Public Health Officer Dr. Theresa Tam.
The following day, Tanguy's email blast observed that the cruise ship's list of positive tests had jumped by another 100. On Feb. 20, he wrote these had escalated further to 542, including 47 Canadians.
As the number of infections jumped, Canada's chief of the defence staff, Jonathan Vance, wrote to his top military and civilian of
ficials. “What is not known is the total of infected with mild or no symptoms,” he wrote. “More information and analysis is needed.”
This kind of crucial detail would have to wait. Vance's department was responsible for airlifting Diamond Princess passengers back to Canada, and cabinet wanted it done. Once back home, the cruise passengers would be the responsibility of Namiesniowski's agency.
Vance's memo noted that the risk to Canadian Forces personnel responsible for screening cruise ship passengers “is assessed as medium.” Vance added that, notwithstanding this assessment, if the passengers were pre-screened in Japan and showed no fever or other overt symptoms, the risk to military personnel handling them “would be reduced accordingly to low.”
This was the same as the risk assigned by the Public Health Agency
of Canada to Canadians generally in the face of the global pandemic.
With 2,400 employees, including 60 per cent in the capital region and nearly 25 per cent in Manitoba, home of the National Microbiology Laboratory, PHAC is a sizable entity.
Its central mission is to watch for infectious diseases ranging from salmonella to influenza. However, its surveillance depends heavily on data from the provinces and, internationally, on WHO, the U.S. Centers for Disease Control and Prevention and the European Centre for Disease Prevention and Control.
PHAC's role as information coordinator makes it an agency of process, often unhelpful when it comes to rapid decision-making. This was evident in the testimony of its top officials this past spring before a House of Commons committee.
On April 22, Sally Thornton, at the time vice-president of PHAC's health security infrastructure branch, had this to say about the agency's shift in thinking about how the virus was being spread.
“Concerning ongoing learning, we are taking note,” she told members of the committee. “For example, more recently, we've been moving our focus from just symptomatic people to include asymptomatic ones, as we learned that people who were asymptomatic can transmit.”
This was nearly three months after Rothe first warned about her asymptomatic carrier in Germany.
A few weeks earlier, Namiesniowski offered members of the same committee her perspective on the use of face masks, framing the issue this way:
“We always are open to what the
science is telling us. We also recognize from the point of view of individuals that they make personal choices about what makes them feel comfortable,” she said. “If they feel the need to wear a mask, we believe that is something which individuals have a right to do.”
It was an odd way of framing the issue. Rather than encourage people to wear a face mask, Namiesniowski backed into a policy. The message seemed to be if you want to wear a mask, we're not going to stop you.
Both Thornton and Namiesniowski left their positions in September. Thornton retired while Namiesniowski joined the privy council office as a senior official.
Of course, it wasn't just the danger of symptomless spread that the Public Health Agency of Canada downplayed. The agency also got caught looking the wrong way when the virus was preparing to invade North America.
What happened on the cruise ship is a preview of what will happen when this virus makes its way to the U.S. health-care system ...
It was a sign that something was very wrong. Quebec health authorities on Feb. 28 revealed the province's first positive test for COVID-19, a traveller from Iran.
For weeks, the Public Health Agency of Canada had been monitoring the flow of travellers from China's Hubei province and nearby countries. Nearly 58,000 travellers from China had disembarked in airports in Vancouver, Toronto and Montreal between Jan. 22 and Feb. 18, including more than 2,000 from Hubei province. This, according to the situation report PHAC shared with other federal government departments.
On Feb. 29, the beginning of spring break, PHAC's priorities would start to shift dramatically. Tens of thousands of Quebecers were preparing to board aircraft bound for Europe, the Caribbean and the southern United States.
We now know the consequences in some detail. The upshot: it took just a few sparks to create a conflagration. None were lit by travellers from China.
A study published in September by McGill University's Genome Centre and the Institut national de santé publique du Québec analyzed 734 genome sequences obtained from infected Quebecers up to April 1. About 45 per cent involved patients with a recent travel history.
Epidemiologists are able to track various strains of the virus by studying its genetic mutations as it multiplies through the population.
One in three of the travellers' genomes analyzed by McGill and INSPQ originated in Europe, with nearly one in three from the Caribbean and Latin America. Twenty-four per cent of the infected travellers acquired the virus in the United States.
“Most of the early introductions of the virus into Quebec did not give rise to sustained transmission,” said Dr. Jesse Shapiro, associate professor of McGill's department of microbiology and immunology. “But a barrage of introductions just after spring break eventually gave rise to the tens of thousands of cases we have seen since.”
A surprisingly large percentage of infections in B.C. and Ontario also originated in Europe and the U.S.
Dr. Bonnie Henry, B.C.'s chief health officer, noted this past June that while the first group of genomes in B.C. were from China and Washington state, by April a majority of the COVID-19 infections were caused by viruses with roots in Europe and Eastern Canada.
Likewise in Ontario, the first few genomes traced back to China, but the numbers with alternate heritage quickly overwhelmed these, according to Nextstrain, an opensource project tracking the evolution of the SARS-CoV-2 pathogen.
More than half of the 100-plus genomes sampled between January and June were from Europe, and more than 40 per cent originated in the U.S. and other parts of North America, the Nextstrain data suggests.
While Quebec's spring break ended March 9 — a full week before the comparable holiday was due to begin in Ontario and B.C. — all provinces coped with an even bigger invasion of travellers beginning mid-March.
That's when Minister of Foreign Affairs François-Philippe Champagne urged Canadians and landed immigrants to return to Canada before the borders closed, thus triggering one of the most remarkable migrations in the country's history.
Between March 14 and March 20, when the U.S.-Canadian border clanged shut to non-essential travel, nearly one million people travelling on Canadian passports headed home.
Half a million travellers jammed airport terminals, many without face masks, convinced they were heading back to relative safety. At customs, harried border and airline officials scanned travellers while handing out pamphlets that urged self-quarantine and contained instructions about what to do if COVID-19 symptoms erupted.
The ramifications of the great return were profound. During the final two weeks of March, the number of confirmed cases in B.C. jumped to 970 from 64, and surged to 1,004 in Ontario from 79. Quebec, though, was the shocker. In that short span, the number of Quebecers with infections rocketed to nearly 4,200 from just 17.
Quebec was, and remains, the epicentre of Canada's COVID-19 spread. Shapiro said fewer than 250 infections (“introduction events”) were the catalysts.
As of mid- October, Quebec's cumulative COVID-19 case count had reached 89,000, or nearly half the national total for a province with one-quarter the country's population.
Despite aggressive testing for the virus, Quebec never got ahead of it. Nor did the country as a whole.
Even now, during a robust second wave of infections, there is something about the nature of the SARS-CoV-2 virus that is keeping real fear at bay. Author Laura Spinney noted a similar characteristic in the virus that produced the great influenza of 1918-1920.
That cataclysmic pandemic circled the globe multiple times, infecting 600 million (one-third of the total population) and killing an estimated 50 to 60 million.
“(It) is a difficult pandemic to pigeonhole,” Spinney wrote in her history of that era, Pale Rider: The Spanish Flu of 1918 and How It Changed the World. “It killed horribly, and it killed many more of its victims than any other flu pandemic we know of,” she noted, “yet for around 90 per cent of those who caught it, the experience was no worse than a dose of seasonal flu.
“As a result,” she observed, “people didn't know how to think about it; they still don't.”
Much the same can be said of COVID-19, which also punishes a disproportionate few while leaving the vast majority in relative good health. COVID-19 as of mid- October had infected 38.5 million worldwide and killed 1.1 million. This means 0.5 per cent have been infected. Fewer than three per cent of those infected have died.
In Canada, the infection rate is the same: 0.5 per cent of the population. But thanks to our egregious record in long-term care homes, fully five per cent of Canadians infected with COVID-19 have died.
Yet even these numbers make SARS-CoV-2 seem comparatively benign, though it will not seem that way to those affected or to patients suffering long-term health issues such as extreme fatigue, mental confusion and damage to the heart and lungs.
It's this aspect of COVID-19, the extremely long odds of a terrible outcome for individuals, that makes it so difficult to contain.
Public officials talk about the paradox of success. Canada and many other countries hammered down the curve of infections this past summer at great social and financial cost. Then we let down our guard. A few house parties, wedding celebrations and other social events provided kindling for the blaze of infections.
In her account of the 1918-20 pandemic, Spinney notes a nearly identical phenomenon. “The group identity splinters and people revert to identifying as individuals,” she wrote. “It may be at this point — once the worst is over, and life is returning to normal — that truly bad behaviour is most likely to emerge.”
The great influenza was marked by a series of infectious waves before it finally burned out. In several important ways, it presaged the strange cultural wars that are roiling this year's pandemic.
Spinney points out that health officials in 1918 disagreed about whether face masks reduced the risk of transmission. And, despite plain evidence of the disease's virulence, hospitals and cemeteries were overwhelmed, there was debate in certain quarters about whether it was real. In October 1918, Spinney noted, “there were still those among Rio de Janeiro's opinion-makers who doubted the disease was flu.”
The physical attributes of the 100-year-old virus, along with the symptoms these produced, found echoes in SARS-CoV-2. The great influenza, for instance, could be spread asymptomatically and affect people's health long after the initial flu had vanished.
One of the main lessons of the 1918-20 pandemic involved the role of physical distancing. Cities that banned large gatherings and ordered the wearing of face masks cut the toll of infection and death substantially. “The timing of the measures was critical,” Spinney concluded. “They had to be introduced early and kept in place until after the danger had passed.
“If they were lifted too soon,” she continued, “the virus was presented with a fresh supply of immunologically naive hosts, and the city experienced a second peak of death.”
That is where we are today, the major difference being that we have the realistic hope of a vaccine in the months to come. We do not, as in 1918, have to wait for the virus to exhaust the supply of human hosts.
But we do bear collective responsibility for minimizing the spread still occurring. The earlier neglect to take the full measure of this virus quickly must now be paid for in the form of physical isolation and targeted economic lockdowns.
That failure belonged to Canada's top health officials and the politicians they advised. The next failure to contain the virus will be on the rest of us.
A barrage of introductions (of the virus) just after spring break eventually gave rise to the tens of thousands of cases (Quebec has) seen ...