What Canada must learn from its flawed COVID-19 response to get ready for a second wave

By | May 15, 2020

What went wrong? What can Canada do to fix it before the next wave hits? This detailed look at Canada’s delayed response to the coronavirus outbreak is part of the Post’s ongoing Lessons from a Pandemic series.

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 January 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 had 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.

Dr. Jerome Leis, medical director of infection prevention and control at Sunnybrook Health Sciences Centre, co-authored the first Canadian study of a COVID-19 patient in Toronto. Sunnybrook Health Sciences Centre

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 unfeeling 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.

Canada’s Chief Public Health Officer Dr. Theresa Tam provides a novel coronavirus update during a news conference in Ottawa on February 3, 2020. Blair Gable/Reuters

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.

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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 long term care.

As April arrived, the nation witnessed a frenzy of panicked buying to secure an adequate supply of personal protective equipment (PPE) for frontline health-care 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 Federation of Nurses 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. Stay-at-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, whom to admit, whom 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.”

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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.

Crosses placed at the Camilla Care Community long-term care facility where fifty people have died of COVID-19, Monday May 11, 2020. Peter J Thompson/National Post

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.

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

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.”

A timeline of the virus

Dec. 31: WHO’s China Country Office informed of cases of pneumonia of unknown cause detected in Wuhan City, Hubei province of China. Outbreak believed to have been in seafood and poultry market in the city of 11 million in central China. However, the first human infections in China may have occurred in November, 2019, or earlier.

Jan. 14: Public Health Agency of Canada’s assessment of public health risk to Canada is “low.”

Jan. 20: Canada’s chief public health officer, Dr. Theresa Tam, tells reporters that, out of “an abundance of precaution,” travellers will be asked at electronic immigration kiosks at Toronto, Montreal and Vancouver international airports if they have travelled to virus-affected areas and to report flu-like symptoms to border services agents.

Jan. 23: Chinese authorities close off Wuhan, cancelling planes and trains leaving Wuhan, suspending buses, subway and ferry services; second city in China, Huanggang, placed in lockdown.

Jan. 23(same day): A 56-year-old man arrives at Toronto’s Sunnybrook Health Sciences Centre’s emergency department with fever and dry cough following return from Wuhan the day before. Canada’s patient zero. He’s discharged home on Day 8 of hospital stay. His wife is confirmed positive. Both recover fully with home isolation.

Jan. 29: Tina Namiesniowski, president of the Public Health Agency of Canada (PHAC), tells federal health committee “currently, our objective is confinement, to limit the impact and spread of the virus …. The system is working as expected.” There are now three confirmed cases in Canada, one in Ontario and two in B.C. Tam defends policy of voluntary self-isolation of only travellers showing clear symptoms. “For other completely asymptomatic people, currently there’s no evidence that we should be quarantining them,” Tam says.

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Jan. 30: WHO declares novel coronavirus a “public health emergency of international concern.” Person-to-person spread is confirmed in four countries (Germany, Japan, Vietnam and the United States) outside of China.

Feb. 6: Tam recommends all travellers returning from Hubei province to stay at home and limit contact with others for 14 days. By now, the U.S., Japan, Philippines, New Zealand and Australia have closed their borders to foreign travellers from China.

Feb. 19 and 21: Cases reported in Iran and Italy with no known direct link to Mainland China.

Feb. 20: Canada reports its first case related to travel outside China in a traveller from Iran.

March 4: Federal Health Minister Patty Hajdu says that, as more countries experience outbreaks, “the less relevant borders become. A virus knows no bounds.” At the same media briefing, Tam says a border “is the spot where you provide people information as to what they should be watching out for and what they should do if they get sick.”

March 7: Federal health officials continue to stress risk to Canadians is low. There are 54 confirmed and “presumptive” cases, most in Ontario and B.C. Tam repeats that Canada is well prepared to deal with the pandemic.

March 8: A man in his 80s, a resident of the Lynn Valley Care Centre in North Vancouver, dies of COVID-19, the first person in Canada to succumb to COVID-19.

March 9: Italy expands quarantine from the Lombardy region to entire country as Italy’s case counts surge. Canada’s Deputy Prime Minister Chrystia Freeland writes to provincial and territorial premiers asking them to tell federal government of any critical gaps in supplies or capacity to deal with the pandemic. Canada begins importing cases from India, the U.K. and the U.S. Evidence grows the virus can be spread by people before they develop symptoms.

March 11: WHO declares COVID-19 a global pandemic.

March 12: Ontario premier Doug Ford tells Ontario families to “travel” and “have fun” on March Break.

March 13: Health Canada advises Canadians to avoid all non-essential travel abroad.

March 15: Tam elevates risk from low-risk to “serious.” Testing still remains focused on travel-related cases.

March 16: Prime Minister Justin Trudeau announces Canada is shutting its borders to travellers from other countries other than the United States, effective Mar. 18. “If you’re abroad, it’s time for you to come home. If you’ve just arrived you must self-isolate for 14 days.” PM tells all Canadians to stay home as much as possible. Hospitals in B.C and Ontario begin cancelling thousands of elective surgeries to free up hundreds of beds, as well as ICUs and ventilators, for COVID-19 patients and moving anyone who can be moved to “alternate facilities.”

March 21: Canada – Travel ban extended to all non-essential U.S. travel. Canada-U.S. border temporarily closed, with limited exceptions.

March 24: Tam formally announces community spread of COVID-19, marking what she calls a “fundamental shift” in transmission of the disease in Canada. But there is evidence local transmission was occurring as early as March 2, after Sudbury man in his 50s tests positive for the virus he was believed to have contracted at a mining conference in Toronto Mar. 2 and 3.

March 30: Tam says that, based on current scientific evidence, putting a mask on an asymptomatic person is “non beneficial.” “What we worry about is the potential negative aspects of wearing a mask,” including giving people a false sense of confidence. In Ontario, all people over the age of 70 are urged to self-isolate.

April 1: Hajdu admits the federal government didn’t maintain adequate supplies of protective gear, including surgical masks in its emergency stockpile. “We likely didn’t have enough.”

April 6: Tam recommends people wear a face mask while shopping or riding public transit, saying a non-medical mask can reduce the chance of respiratory droplets coming into contact with others or landing on surfaces.

April 12: After telling Canadians “we all have to stay home,” Trudeau travels to Harrington Lake in Quebec to spend Easter with his family at their official country home, posing with wife, Sophie Gregoire Trudeau, and their children for an Instagram selfie.

May 4: Confirmed cases of COVID-19 in Canada surpass 60,000. Three-quarters of Ontario’s 1,300 deaths linked to outbreaks in long term care facilities. Across Canada, deaths in long term care now account for more than 80 per cent of the roughly 4,500 deaths from COVID-19.

May 5: Ontario Premier Doug Ford warns regional medical officers to “start picking up your socks” over testing delays. Some areas facing shortages of swabs.

May 7: Ontario hospitals begin resuming scheduled surgeries.

May 8: Fifth personal support worker in Ontario dies of COVID-19.

May 11: Quebec’s death toll surpasses 3,000 as schools reopen.

May 14: Canada surpasses 72,000 cases and 5,300 deaths related to COVID-19.

(Sources: Canadian Medical Association Journal, Canadian Healthcare Network, Infection and Prevention Control Canada).

Health – National Post