H5N1

BC’s top doctor wrote a book about fighting viruses in 2009

The Tyee has published my article: BC’s Top Doctor Wrote a Book about Fighting Viruses in 2009. Excerpt:

Soap and Water & Common Sense: The Definitive Guide to Viruses, Bacteria, Parasites, and Disease By Dr. Bonnie Henry House of Anansi, 2009. 

Dr. Bonnie Henry’s news conferences have become a part of daily life in B.C. When they attend her briefings, Premier John Horgan, Health Minister Adrian Dix, and Public Safety Minister Mike Farnworth fade into the background, at a safe distance from her and one another. They speak chiefly to endorse what their chief medical officer says. The contrast with Trump’s press conferences is impossible to miss. 

It certainly helps that Dr. Henry can deliver alarming news in a calm tone of voice, without relying on technical jargon; we pay attention, we absorb the news, but we don’t freak out. Treated like adults, we respond like adults.  

Those same communication skills are evident throughout her 2009 book Soap and Water & Common Sense, written years before she became B.C.’s provincial health officer. The book is now available with a new introduction, written in March, and the content itself is still very timely: while our healthcare system is fighting COVID-19, other diseases are going to exploit their opportunity.

Q&A: New York emergency room doctor says it’s just getting 'worse and worse’

Via Caixin Global: Q&A: New York Emergency Room Doctor Says It’s Just Getting 'Worse and Worse’. Note the reference to a doctor becoming reinfected; I haven't heard of that before. Excerpt:

Nineteen shifts in 22 days. 

That’s what New York City emergency room (ER) doctor Calvin Sun has worked since the Covid-19 outbreak began in the city. As a per-diem doctor, Sun works on something like a freelance basis, picking up shifts at whichever hospital in the city has a 10- to 12-hour hole to fill in its ER schedule. This experience has given him a broad perspective about the state of the city’s emergency rooms as New York has become the epicenter of the U.S. outbreak. On Thursday, the day Sun spoke with Caixin, the state of New York recorded 562 deaths from Covid-19. 

Sun described the increasingly desperate-looking situation at New York City ERs, as younger, sicker patients seek treatment in droves even as the local health care system strains under the pressure. Some hospitals are setting up tents outside to handle surging patient numbers, while personal protective equipment (PPE) is in short supply that Sun has been taking donations to keep himself kitted out in “cobbled together” gear. 

This interview has been edited for length and clarity.  

Caixin: When did you start dealing with Covid-19? 

Dr. Calvin Sun: I started working at exactly 7 a.m. on March 8. I was co-leading a trip in Angola up until March 7 at 6 p.m. And then my first shift was 7 a.m. the next morning. So, once I landed, I got immediately straight to work and I haven’t stopped since. 

I think I’ve worked 19 shifts in the last 22 days. So tomorrow will be my 20th shift — I just picked it up five minutes ago because a doctor just got reinfected with Covid-19. And Saturday, I just picked up another shift for another doctor that got infected with Covid-19. 

How many hours can you rest in between shifts? 

I’m a per-diem, so I work however much as I want. I usually do 10- to 12-hour shifts — tomorrow’s is 10 hours, Saturday is nine hours, yesterday’s was 12 hours. But when I go home, I go home — you know, go to sleep.  

How has the situation changed in the past month or so? 

It has just been getting worse and worse. The patients are coming in sicker. They are coming in younger. More patients are coming in. The volume is higher. And more field tents are being set out outside the hospitals to manage the surge capacity. And we’re running low on resources. It was already understaffed and difficult before this pandemic.  

There have been reports of shortages of PPE and medical workers. Have you seen improvement on these fronts?  

Everything is a sign of progress in terms of effort, and trying to fill in the holes … We need to fight this pandemic as a warlike effort, but it’s just that I think there was a difficulty in the supply chain in getting us equipment because the other countries that were (producing) this personal protective equipment were shut down because they were also fighting this pandemic … We’re just doing our best right now by the ingenuity of the people who are staying at home, who are not working. They’re creating masks. They’re trying to give donations. They donating to the right people. And I’m accepting personal private donations. I’m distributing to my friends if I have too much of anything. And yeah, we’re just making a huge effort right now to make sure everyone is adequately protected. 

My PPE is cobbled together for the many different emergency rooms that I work in. I’m lucky — if that’s even a word I can use nowadays — to be per diem, so I have access to different emergency rooms and their equipment. But every emergency room is always lacking something. It’s always something different. But I put something together for myself and have been getting by until my family and loved ones were able to donate something that was a little more comprehensive. 

Are many medical workers getting sick?  

It’s part of the nature of our work that we get sick … Every patient that we take care of — we’re exposed to what they have, and sometimes we get sick.  

This is a little scarier because we’re getting sick with a virus that we know very little about. And it kills people very quickly. Unlike cancer or heart attacks — more people die from those — but people die in a more drawn out setting — a few heart attacks a day. But with Covid-19, you get infected really, really quickly because it is so contagious … It’s like, McDonald’s sells 2.5-3 billion hamburgers every year. That’s a lot, but they can handle it, right? But imagine you drive up to a McDonald’s and ask for 50,000 burgers in one day. That’s going to overwhelm the system, and that’s what we’re dealing with right now.

How are the emergency rooms operating right now?

Just because you have a quarantine doesn’t mean the rates of heart attacks are less. Maybe (there is) less trauma because there are fewer people outside, but every now and then I still get the occasional motor vehicle accident that comes into the emergency room, and we have to take care of them too. And when they come in, they may get exposed to Covid-19 just simply because a lot of our emergency rooms are structured as one giant room where patients are separated by curtains. Instead of every patient getting their own rooms. We just don’t have that space in a place like New York City.

What are you thinking every time you go to a shift?

It is scary. You’re battling a virus that you don’t know, that’s an invisible enemy, that’s very infectious — and you can bring that home.

I can imagine it being daunting for anyone in our shoes to rush, you know, into a burning building, fighting a fire that you cannot see. Inhaling all that smoke. Not adequately protected — naked — as the building is about to collapse on you. And your job is to try to get everyone outside of this burning building before it completely collapses, but you’re also trapped inside. That’s how I usually feel.

But personally, I’m trained for this … Disaster medicine is my thing … But I can’t speak on behalf of my colleagues who may not have signed up for things like that and may not be interested in that area of emergency medicine. So, it is something that a lot of us are adjusting to.

US: Inside the COVID-19 testing failure

Via The Washington Post: Inside the coronavirus testing failure. Excerpt:

On a Jan. 15 conference call, a leading scientist at the federal Centers for Disease Control and Prevention assured local and state public health officials from across the nation that there would soon be a test to detect a mysterious virus spreading from China. Stephen Lindstrom told them the threat was remote and they may not need the test his team was developing “unless the scope gets much larger than we anticipate,” according to an email summarizing the call. 

“We’re in good hands,” a public health official who participated in the call wrote in the email to colleagues. 

Three weeks later, early on Feb. 8, one of the first CDC test kits arrived in a Federal Express package at a public health laboratory on the east side of Manhattan. By then, the virus had reached the United States, and the kits represented the government’s best hope for containing it while that was still possible. 

For hours, lab technicians struggled to verify that the test worked. Each time, it fell short, producing untrustworthy results. 

That night, they called their lab director, Jennifer Rakeman, an assistant commissioner in the New York City health department, to tell her it had failed. “Oh, s---,” she replied. “What are we going to do now?” 

In the 21 days that followed, as Trump administration officials continued to rely on the flawed CDC test, many lab scientists eager to aid the faltering effort grew increasingly alarmed and exasperated by the federal government’s actions, according to previously unreported email messages and other documents reviewed by The Washington Post, as well as exclusive interviews with scientists and officials involved.  

In their private communications, scientists at academic, hospital and public health labs — one layer removed from federal agency operations — expressed dismay at the failure to move more quickly and frustration at bureaucratic demands that delayed their attempts to develop alternatives to the CDC test.  

“We have the skills and resources as a community but we are collectively paralyzed by a bloated bureaucratic/administrative process,” Marc Couturier, medical director at academic laboratory ARUP in Utah, wrote to other microbiologists on Feb. 27 after weeks of mounting frustration.  

The administration embraced a new approach behind closed doors that very day, concluding that “a much broader” effort to testing was needed, according to an internal government memo spelling out the plan. Two days later, the administration announced a relaxation of the regulations that scientists said had hindered private laboratories from deploying their own tests.  

By then, the virus had spread across the country. In less than a month, it would upend daily life, shuttering the world’s largest economy and killing thousands of Americans.  

In a statement to The Post, the CDC said an investigation of the initial problems is ongoing. The test is now in use in every state and is “accurate and reliable,” the agency said.  

Stephen Hahn, the commissioner of the Food and Drug Administration, which regulates testing, told The Post the agency is continuously adapting to an “unprecedented global public health crisis." 

“Right now, our efforts are focused on doing everything we can do to fight COVID-19, but we know there will certainly be a time to learn larger lessons from the agency’s response,” he said in a statement, referring to the disease caused by the novel coronavirus. 

In an interview Thursday, Brett P. Giroir, a Public Health Service admiral who on March 12 was named the top administration official on the testing effort, acknowledged the government should have moved more decisively to detect and contain the virus. 

“There was a clear need for a more aggressive posture,” said Giroir, an assistant secretary at the Department of Health and Human Services, adding that agency leaders named him to the new role because “unprecedented steps needed to take place.” 

Asked who was responsible for the delays in the early stages of the crisis, he paused.  

“A problem like this is bigger than any single agency,” he said. “Clearly, there needed to be a higher level of leadership and organization.”

WHO Director-General's opening remarks at the Mission briefing on COVID-19 - 2 April 2020

WHO has published WHO Director-General's opening remarks at the Mission briefing on COVID-19 - 2 April 2020. Excerpt:

I’d like to begin by thanking Member States for last week’s briefing. It was inspiring to hear from China, Japan, the Republic of Korea and Singapore about their experience and the lessons they have learned. We plan to do another similar briefing in a few weeks’ time, when we will have even more experiences to share from Europe and elsewhere. 

As I said at yesterday’s press conference, this is a new virus, and the first pandemic caused by a coronavirus – two firsts. We are learning as we go, reviewing the evidence and adapting our recommendations as necessary.  

In the next day or two, we will reach more than 1 million confirmed cases of COVID-19 globally, and 50,000 deaths. This virus, which was unknown to us three months ago, has exposed the weaknesses and inequities in our health systems and societies, our lack of preparedness, and the gaps in our supply chains and other essential systems.  

We have to prepare our health systems for large numbers of cases, even as we maintain essential health services. We know that when health systems are overwhelmed, mortality from vaccine-preventable and other treatable conditions will increase dramatically. Gaps in essential care can result in many more deaths than the coronavirus itself.  

WHO has recently published guidance on maintaining essential health services while responding to COVID-19. This is one of more than 40 pieces of detailed, evidence-based guidance to guide countries in the response. Every day, we are engaged in numerous discussions with our extensive networks of experts to refine our guidance to reflect the best science. 

Our press conferences are a good way for us to highlight key messages for the world at large, but they are no substitute for technical guidance. We urge all countries to read and implement this guidance. We also recognize the need to adapt our guidance for different settings, especially in the poorest and most vulnerable communities. 

For example, we recommend handwashing and physical distancing, but we recognize that we need innovative solutions for communities that lack clean water, or live in cramped conditions. WHO, UNICEF and the International Federation of the Red Cross is calling for countries to provide free public hand hygiene stations in areas without access to water and sanitizer.  

We are already seeing the economic and social effects of this pandemic in high-income countries. In poor communities, those effects could be even more severe and long-lasting. We are calling on governments to provide a social safety net, so that vulnerable people have food and other essentials during this crisis. WHO, the World Bank and the IMF have united in a call for debt relief for developing countries, to enable them to implement those measures.

COVID-19 pandemic in west Africa

Via The Lancet Global Health: COVID-19 pandemic in west Africa.

The coronavirus disease 2019 (COVID-19) outbreak, which started in the Hubei province of China in 2019, has now spread to all continents, affecting 177 countries by March 27, 2020. Successful efforts in containing the COVID-19 virus in Asia resulted in WHO declaring Europe as the epicentre of the disease on March 13.Whether warmer temperatures will slow the spread of the COVID-19 virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been a point of much speculation. This hypothesis has led some European countries to produce initial policies relying on decreased transmission rates during the summer months, and the belief that African countries will face smaller epidemics than their European counterparts. However, no strong evidence base exists for such claims; SARS-CoV-2 might have simply arrived later to warmer countries. 

We used data from the COVID-19 data repository of the Johns Hopkins Center for Systems Science and Engineering (Baltimore, MD, USA) to plot the cumulative number of cases since the diagnosis of both the first patient and the first five patients by country, both in Europe and Africa. Although the first confirmed COVID-19 cases occurred later in west Africa than in Europe, once these first cases were confirmed in west Africa, the expansion in the number of confirmed COVID-19 was rapid. 

Of particular concern are Burkina Faso and Senegal, which saw sharp increases in the number of cases soon after the initial cases were confirmed in these countries. Cases in both countries might evolve in a similar way to what was observed in European countries with the most expansive epidemics (ie, Italy and Spain, where SARS-CoV-2 spread quickly after case number five was detected). Senegal also confirmed its first three cases of community transmission on March 21,4 suggesting more cases in this country than the 119 confirmed on March 27. 

The impact of a similar epidemic as currently seen in Europe would be devastating in west Africa. Although some west African countries have measures in place from the 2014 Ebola epidemic, the region includes some of the poorest countries in the world (according to World Bank data, nine of the 25 poorest countries are in the region). In addition, many west African countries have poorly resourced health systems, rendering them unable to quickly scale up an epidemic response. Most countries in the region have fewer than five hospital beds per 10 000 of the population and fewer than two medical doctors per 10 000 of the population (based on WHO global health observatory data), and half of all west African countries have per capita health expenditures lower than US$50 (based on WHO global health expenditure data. 

In contrast, Italy and Spain have 34 and 35 hospital beds, respectively, per 10 000 of the population, 41 medical doctors per 10 000 of the population, and US$2840 and US$2506 per capita expenditure. Despite having young populations (old age is a major risk factor for severe forms of COVID-19 and mortality), some west African countries have rates of other risk factors similar to European countries. For instance, 27% of Gambians have hypertension and 6% have diabetes. 

We believe the epidemic has started later in west Africa than for other regions globally because of the limited international air traffic, rather than the climate conditions. Now that community transmission is ongoing in some countries, the amount of time to prepare an epidemic response is limited. Early identification of confirmed cases, swift contact tracing with physical isolation, community engagement, and health systems measures are all necessary to avert the potentially harmful consequences of an epidemic in the region. 

To conclude, early comparisons between the number of confirmed cases in the worst affected European countries and the west African countries with confirmed COVID-19 cases do not support the hypothesis that the virus will spread more slowly in countries with warmer climates. In the case of west Africa, a rapid acceleration in the number of cases could quickly overwhelm already vulnerable health systems. Swift action to control further spread of the virus, and to improve the response capabilities of affected countries in west Africa is therefore urgent.

COVID-19: Recent Canadian updates on the coronavirus pandemic

Via CMAJ: COVID-19: Recent updates on the coronavirus pandemic. Excerpt:

Apr. 1: More than 100 deaths in Canada linked to COVID-19 

• Canada reported 105 deaths related to COVID-19 and more than 9,000 confirmed cases. Quebec has the most cases in Canada, with 4,162 infections and 31 deaths. 

• Prime Minister Justin Trudeau declined to answer how many more deaths are expected based on federal modelling, or how long physical distancing measures will remain in place, saying there are various scenarios. 

• Companies that help people with advance planning reported that unprecedented numbers of Canadians made wills and signed powers of attorney in the past two weeks.  

Apr. 1: Looming drug shortages 

• Global supply chain problems related to COVID-19 will probably lead to shortages of drugs and medical devices, according to deputy health minister Stephen Lucas. Health Canada is working with regulators in the United States, Australia and Europe to spot where disruptions may occur and find substitute products, Lucas told the House of Commons health committee. 

Apr. 1: Provinces building makeshift hospitals 

• Three provinces announced plans to set up makeshift hospitals in repurposed buildings. British Columbia is outfitting a Vancouver convention centre, while Ontario is allowing hospitals to temporarily lease space in hotels and retirement homes and Quebec has identified 4,000 hotel rooms that could be used. 

Apr. 1: Researchers face layoffs as non-essential trials shut down 

• Research programs are unsure if and how they can use federal grant money to continue paying employees while studies unrelated to COVID-19 are on hold. University Health Network in Toronto is preparing to lose a projected $6 million a month as a result of the shutdown. However, the Canadian Institutes of Health Research confirmed that staff pay is an eligible grant expense given the “exceptional” circumstances. 

Apr. 1: Many COVID-19 cases may be asymptomatic 

• A quarter of people with COVID-19 may not show symptoms but still spread the virus, according to the United States Centers for Disease Control and Prevention. In Iceland, one screening program that has tested about 9,000 self-selected people reported that about half of those who tested positive for COVID-19 were asymptomatic. 

Apr. 1: Growing debate over face masks 

• Some health experts argued Western countries have made a mistake by discouraging healthy people from wearing face masks, given that asymptomatic people can spread the virus. Health officials in some Asian countries point to pro-mask policies as key to controlling the pandemic, and this week Austria banned members of the public from entering supermarkets without wearing one.

Speranza on COVID-19 in Italy: 'Containment measures confirmed until April 13th. The road is still long and we must not let our guard down because without the vaccine we will not be able to definitively defeat the virus'

Via the Ministry of Health: Covid-19, Speranza: “Containment measures confirmed until April 13th. The road is still long and we must not let our guard down because without the vaccine we will not be able to definitively defeat the virus." The Google translation:

Health Minister Roberto Speranza spoke to Parliament today, in the Senate in the morning and at 5pm in the Chamber - follow the live broadcast on the Chamber's web TV - with a report on the emergency from Covid-19. 

The minister announced the government's decision to confirm until April 13 all the measures taken to limit economic and social activities and individual travel previously adopted. "Not only must we not let our guard down," the minister underlined, "but for a short period it will be necessary to manage the transition, grading the measures and keeping the practices adopted to avoid new outbreaks: it is the only realistic and practicable way to restart the engines of the economy and regaining freedom and sociability. Italy should be proud of the work done that has been recognized by the WHO, with which the relationship is continuous and fruitful."    

The minister also spoke on the critical issues encountered and addressed "The supply of protective devices," said Speranza, "has been very difficult due to the protectionist measures and the lack of Italian production. To date, the Civil Protection has concluded an agreement with China and other countries for the supply of 300 million masks (priority will be given to healthcare personnel) and we will have a national supply chain that makes the country self-sufficient. The methods of distributing devices have changed with the use of defense means. The ICU beds were increased to 9,081, the pulmonology beds were tripled. The ordinary roofs for hiring staff were exceeded and the guidelines for hospitals were updated (increase in Covid hospitals)." 

The minister also intervened on vaccines and drugs under experimentation, underlining: “The drug agency has activated itself on four levels: promotion of clinical studies and centralized and coordinated evaluation, list of drugs for the treatment of infection, contrast of the shortage of medicines , information on drugs. The Minister is committed to maximum vigilance to avoid speculation to the detriment of the sick. We need to go back to developing the network of territorial services with hospitals and we need a renewed integration between health and social policies." 

In his information Speranza also wanted to underline how valuable our national health service is: "The emergency has shown that the universal health service, established in 1978, which implemented article 32 of the Constitution, is the most precious and we must invest in it: taking it as a theme for strategic recovery is the best way to honor the victims."

Investigating COVID-19: ICIJ African partners warn of looming threat

Via the International Consortium of Investigative Journalist: Investigating the coronavirus: ICIJ African partners warn of looming threat.

There are not enough masks, not enough ventilators, and in some hospitals, not enough healthy nurses and doctors.  

The coronavirus outbreak raging across Europe and North America has exposed planning failures and weaknesses of health systems generally considered the finest in the world. Across much of Africa, in countries with far fewer resources to begin with, the toll of the viral pandemic could be much, much worse, ICIJ partners on the continent say. 

“A patient tsunami would be fatal for Senegal,” said Momar Dieng, a reporter for Ouestaf in the West African nation. 

Dieng and two other ICIJ partners on the continent, Mohamed Kabba in Sierra Leone and Tatenda Prosper Chitagu in Zimbabwe, said their countries are ill equipped to handle a surge of patients needing intensive care – particularly the respiratory therapy the sickest COVID-19 patients require. 

As of Tuesday morning, Senegal had reported 162 coronavirus cases and Madagascar 46. Zimbabwe had recorded eight. Sierra Leone just reported its first case. 

Senegal, one of the most developed countries in West Africa, doesn’t have enough hospitals to begin with, Dieng said. Of those that do exist, only a handful, mostly clustered in Dakar, the capital, have the expertise to care for patients with severe coronavirus symptoms.

Dieng said that as cases mount, he and his colleagues have been limited to conducting interviews by phone or email. Reporting from the field, he said, “is almost impossible because the press is strictly prohibited from entering the centers where the patients are isolated.” 

Sierra Leone, another West African nation, still hasn’t recovered from the Ebola epidemic, which killed more than 3,500 people in 2014 and 2015. 

The government moved early to prevent a coronavirus outbreak, Kabba said. On Feb. 2, it began requiring travelers from any country with more than 50 coronavirus cases to quarantine on entering Sierra Leone, he said. It has since shut down most air travel.  

The health care system, Kabba said, is not prepared for a surge of cases. The Ebola treatment centers are closed and most hospitals can’t accommodate COVID-19 patients, he said. And there has been “no transparency” from the government about how much it is spending to prepare for the pandemic, he said. 

Zimbabwe is in worse shape, said Chitagu, a reporter with Newsday. “Our health system is in shambles,” he said. “The country’s first isolation center in [the capital] Harare, does not have a ventilator, oxygen, running water or even a working socket.”  

Nurses don’t have protective clothing, Chitagu said. Hospitals don’t have drugs. “If there are a lot of people diagnosed with the disease, our hospitals will be overwhelmed,” he said.

Many journalists also don’t have protective gear. “As such, many are keeping their distance, dealing a blow to the nation’s access to information on the disease,” Chitagu said. “For now, many have adopted the attitude of ‘no story worth dying for.’”  

Yet, tragically one has already died. The first officially recorded death caused by COVID-19 in Zimbabwe was Zororo Makamba, a 30-year-old radio and television host, and one of the country’s most prominent journalists.

New China COVID-19 data undercuts reassurances by our health officials

Sorry for the pause in blogging; I've been working on a Tyee piece based on the CMAJ article I linked to this morning. Its author, Dr. Peter Phillips, head of the infectious diseases division of the UBC School of Medicine, kindly cooperated. Here's my take: New China Data Undercuts Reassurances by Our Health Officials. Excerpt:

Every afternoon, B.C.’s Provincial Health Officer Dr. Bonnie Henry and Health Minister Adrian Dix offer a daily update on the COVID-19 situation across the province. Both offer solid performances, calm, frank, and reassuring even when the news is grim. 

But it’s not really news. Each day’s new cases and deaths reflect some fraction of those who were infected up to two long weeks ago. And some of those mid-March cases may have been caused by persons who showed no symptoms but still carried — and shed — the virus that causes COVID-19. 

Dr. Henry downplayed that possibility in a March 31 interview on CBC Radio’s Early Edition, saying a few such cases might exist and might be a “challenge,” but they were not enough to be concerned about.  

Events have already overtaken her reassurances. That same morning, China’s National Health Commission dropped a bombshell: as of Monday, the Chinese are aware of 1,541 asymptomatic COVID-19 carriers in the country, including 205 imported cases. What’s more, China will henceforth report these as active cases and quarantine them and their contacts just like symptomatic cases. 

Public health experts elsewhere in the world might be excused for swearing under their breath about Chinese secrecy; clearly, the National Health Commission has known about such cases for some time without publishing anything about them. But the new revelation helps to explain why everyone in China is wearing a mask, even when the World Health Organization says only symptomatic people should wear them. 

Our own B.C. C.D.C. says the same thing: “It may be less effective to wear a mask in the community when a person is not sick themselves. Masks may give a person a false sense of security and are likely to increase the number of times a person will touch their own face (e.g., to adjust the mask).” 

Big mistake: no masks  

And that also explains why Dr. George Gao, the head of China’s C.D.C., told Science magazine last week that the biggest mistake the West is making is our failure to make everyone wear a mask: “Many people have asymptomatic or presymptomatic infections. If they are wearing face masks, it can prevent droplets that carry the virus from escaping and infecting others.”  

These developments lend weight to an opinion piece published in CMAJ, the journal of the Canadian Medical Association, on Friday. Its author, Dr. Peter Phillips, is head of the infectious diseases division of the UBC School of Medicine. 

Dr. Phillips is blunt: “Canada’s response to the COVID-19 pandemic is not strong enough. Despite school closures, measures being taken at borders to minimize spread, and social distancing efforts, and despite the recent announcement of $82 billion to support the business community and the economy, more effort is urgently needed. New cases doubled over four days before reaching 1,426 on March 22, which was after a week of containment measures.”  

On March 31, Canada reported 7,474 cases.

Dr. Phillips continues: “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. If the main goal of our response is merely to try to flatten the epidemic curve in order to reduce the extent to which hospitals become overwhelmed, we will fail in Canada.”

Why Canada needs urgent revisions to its COVID-19 response strategy

Via CMAJ Journal, a March 27 opinion piece: Why Canada needs urgent revisions to its COVID-19 response strategy.

Canada’s response to the COVID-19 pandemic is not strong enough. Despite school closures, measures being taken at borders to minimize spread, and social distancing efforts, and despite the recent announcement of $82 billion to support the business community and the economy, more effort is urgently needed. New cases doubled over 4 days before reaching 1,426 on March 22nd, which was after a week of containment measures. 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. 

If the main goal of our response is merely to try to flatten the epidemic curve in order to reduce the extent to which hospitals become overwhelmed, we will fail in Canada. Another very important goal must be to reduce the percentage of the population who will ultimately become infected, which has been estimated to between 10% and as high as 60% if there is inadequate containment, resulting in a massive death toll. Lessons from other countries and recent observations need to be urgently incorporated into our national strategy. 

Taiwan’s early and multifaceted response to COVID-19 successfully prevented uncontrolled spread in the community. It included a comprehensive border policy, mandated supervised quarantine utilizing a short text message service (“mHealth”), and rigorous case finding with contact tracing. Taiwan had previously been predicted to have the 2nd largest number of exported cases outside China, given its proximity and number of daily flights, yet only 252 cases have been reported in Taiwan to date (March 26th), putting it well down the league table of cases by country and illustrating the effectiveness of their public health policy. In contrast, Canada was predicted to have the 14th highest number of cases, but now we have 3,579 cases (March 26th) and are right where we were predicted to be. With a multipronged intervention like Taiwan’s it is difficult to determine which components were most important; however, their success so far challenges a popular view that early temporary travel restrictions (which included quarantine) have more negative consequences than benefits and should not be recommended. While Taiwan’s approach may be difficult to emulate in low resource settings, high resource countries like Canada should be able to follow their example. 

Two clear examples of successful responses to major COVID-19 outbreaks, so far, come from China and South Korea. China’s highly efficient response that included what might be considered “draconian measures” is unlikely to be replicated in Canada. However, democratic South Korea managed to largely control its epidemic with an aggressive approach, which has included extensive testing for case finding, extremely detailed contact tracing, plus mandatory supervised quarantine with fines for infractions of up to $2,500 USD. 

Convincing evidence is now emerging that cases may be contagious for days before they develop symptoms. Such evidence highlights a flaw in Canada’s previous program of allowing people returning from countries deemed to be ‘at risk’ (other than Hubei province and Iran) to self-monitor for symptoms, unsupervised and without self-isolation. That program was recently revised on March 12th to include instruction to returning travelers to self-isolate, but it remained neither mandatory nor supervised.  

Recently announced border control measures should help stem the flow of incoming infected travellers, but will do little to flatten the curve of our epidemic without the use of stronger mitigation strategies such as enforcement of social distancing measures, and supervised mandatory quarantine facilitated by the adoption of mobile phone short text message service. Quarantine has been shown to be more effective than self-monitoring for symptoms for infections where transmission can occur before patients become symptomatic. However, Canada’s Quarantine Service likely needs hundreds of additional staff across the country to accomplish this. 

Furthermore, we need to rapidly scale up diagnostic testing. This is already underway but obstacles include limited availability of testing kits from commercial suppliers, and also a shortage of swabs suitable for viral testing. Health messaging has been misleading regarding “who to test”. It should be clarified that although limited access to testing may make it impossible to test travellers with mild COVID-19 compatible symptoms right away, it is essential that such individuals be tested in the near future if we are to be successful in controlling further spread. Modification of the contact tracing protocol is needed to include testing of contacts of cases during the 2 days before the development of symptoms as recommended by the WHO. 

Canada also needs an increase in public health staffing to accommodate the burgeoning case load that greater requirements for testing will deliver. Increased funding targeted to public health and quarantine services will be needed if we are to follow South Korea’s response plan, over and above the $100M announced by the federal government last week, as well as creation of federally co-ordinated task forces and adequate funding (over and above the recently announced $500M) in order to lead efforts to secure adequate human resources, hospital and intensive care unit bed space, ventilators, personal protection equipment, swabs, facilities to house and support those who are infected but do not require hospitalization and whose housing is inadequate for home isolation.

Rapid scanning of global data could ensure that experience from other countries informs and regularly updates the Canadian response plan. Given the accomplishment of South Korea, which, at least so far, has managed to restrict spread to 0.0002% of their population, and which should be considered the gold standard of public health care, we in Canada should aim for nothing less. Even if this goal is ultimately unsuccessful, it will at least buy precious time which may allow for drug or vaccine development, and improving access to critical supplies.

Those who have strong concerns regarding the negative consequences for human rights due to such disruptive mitigation and containment measures should look more closely at the current situation in Italy, which has seen more than 700 deaths today (26th March) and over 600 per day for the past week. Surely the rights of Canadians who are at greatest risk of becoming seriously ill or dying also need to be considered. Our current epidemic curve suggests that we could end up in a similar situation as Italy in the next few weeks, unless major steps are taken to change the course.

The federal government’s reluctance to adopt disruptive measures until very recently reflects a serious underestimation of the gravity of this pandemic. The upfront costs and disruption to both society and the economy associated with a comprehensive containment strategy are considerably less than that related to an uncontrolled outbreak requiring mass community quarantine. The benefits from the important vaccine and drug treatment development initiatives are likely many months to years away. Canada’s government needs to do more and to do it now.