Peter Phillips is Clinical Professor of Medicine in the Division of Infectious Diseases at the University of British Columbia
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.
With the recent outcry for medical and nursing staff to be mobilized to Ontario, it is more critical than ever before to start thinking about a universal Canada-wide medical licensing for doctors to allow them to move freely between provinces without bureaucratic red tapes, which can take months. It will provide a safety net for the overwhelmed and overstretched healthcare systems during these dire situations.
Totally agree. We should look to Taiwan as a model (even though high functionaries at the WHO cannot even say that name). They did not have to totally lock down to achieve control. We are probably past the point where we can emulate them and greater lock-down restrictions will be warranted here. The government actions have trailed the evidence by about 4-6 wks in my estimation. The “glimmers of hope” they talk about are more likely artifacts due to the limited amount of testing being done. Wide availability of a rapid finger-prick test would be a game-changer. Meanwhile, I think things are going to get much worse before they get better. I hope I am wrong.
Could not agree more!
Too little too late.
I am also concerned about the length of time it is taking to get test results. I have been in quarantine for 17 days now, having returned from travelling abroad for work (I work in health in international Development). I was tested based on my symptoms and travel history on March 23, 2020, and have not yet received my results. If we want to get control on COVID-19, we will need to be testing more people and getting results out faster.
Dr. Phillips, thank you for this!
My take as a retired community medicine physician (as of today, March 30 2020):
• Best would be that this virus never jumped to humans in the first place – but too late for that now,
• Next best would be a safe and effective vaccine ready to vaccinate everybody – but that won’t happen for several years at least; and
• Next best is low-risk people slowly becoming infected with small enough infectious doses of virus so that they don’t get sick but do become immune, until we achieve herd immunity – while minimizing economic harms. (more on infectious dose – https://www.sciencemediacentre.org/expert-reaction-to-questions-about-covid-19-and-viral-load/ )
To slow the spread of the virus, we need a multi-barrier approach. So far, the main components of our response are:
1. Hand washing/surface sanitizing
2. Physical distancing
3. Catching coughs/sneezes in a tissue (not great but better than a bare hand) or sleeve (better)
So far we have not yet deployed:
4. Management of key supplies to ensure continued availability (as is done in Taiwan)
5. Air sanitizing, which in our climate would be either by UV (which prevented pandemic influenza in UV-treated TB wards) or by heating for the time x temperature needed to inactivate the virus
6. Universal mask-wearing to catch expired respiratory droplets whenever away from home in any shared airspace. When we know more about the potential for reinfection, we might be able to excuse from mask-wearing people who have been infected and been shown to have a robust immune response indicating immunity.
I believe the reason Canada isn’t requiring universal mask-wearing is that we have insufficient supplies of commercial one-use masks, whether sold for medical use or industrial use. Based on the premise that less-efficient masks are still much better at catching exhaled respiratory droplets than no masks at all, we could:
A. Call for volunteers to sew fabric masks that can be washed in hot water and dried in the dryer (as is now being done by some hospitals in the US), and
B. Provide instructions for heat-treating one-use masks for the time x temperature needed to inactivate the virus to allow personal reuse of masks. (e.g., at our house, while waiting for any useful official guidance, I figured out a way to get our slow cooker on warm to reach 67oC. I’m using it for between-use treatment of our four industrial N95 masks left over from a past dusty renovation project.)
The benefits of universal mask-wearing:
• Respiratory droplets are caught before hitting shared airspace whether or not the mask-wearers know they are infectious, and
• When everybody is wearing a mask, not as much economic (or medical) activity needs to be curtailed.
From the responses to the JAMA article (https://jamanetwork.com/journals/jama/fullarticle/2762689 )
“I’m another expat living in Taiwan. There has definitely been a sense here that the COVID-19 threat has and continues to be managed competently by the government with community members also responsibly and cooperatively playing their part. That response is visible everywhere, whether coming through immigration control, having my temperature checked each time I enter my campus, using the alcohol hand spray at my favorite coffee shop, or buying masks with my residential card.” (March 5, 2020)
“The Taiwan government not only rations face masks to prevent hoarding, it also created a virtual map guided by GPS that tells you where the nearest pharmacies are and which pharmacy still have face masks in stock. On March 11th, it started on-line ordering of face masks so those who have to work or attend classes can pre-order the mask and just stop by a convenient store to pick them up after work. Citizens are cooperative in this crisis as you hardly see anyone in public space, buses and subways, markets, campuses without a mask.” (March 14, 2020)
Thank you Dr. Phillips, your post echoes my thoughts on this. I can, to a degree, understand why the government has been so unforgivably late in its “societal” responses to the pandemics: tough measures, even if necessary, will not win popularity contest with the electorate… But why oh why have they decided to give up on the epidemiology so early in the game? — that is beyond my understanding.
We need to do all that to flatten the curve so the herd immunity comes gradually and the rate of death is low enough at any given time not to overwhelmed the medical system. May I add also:
1. Masks can be beneficial especially for the asymptomatic spreaders – even the home-made mask. However, that requires leadership. Dr. Tam’s early recommendations included wearing masks.
2. We need Nation wide or consistent recommendations about the timing of de-isolation for the mild positive cases, or presumed cases. It is so variable now from places to places.
Take care and keep positive,
Thanks Xin Chong – we will eventually end up with a more consistent approach. The strength of our Federation is that it allows for differences in priorities and cultures across very diverse populations. Those differences lead to inconsistency in approaches across the country. However frustrating at times, those differences allow us to learn from each others sucsesses and mistakes, which is not a bad thing.
A survey conducted by Innovate Research Group of 2000 Canadians between March 23-26, after mandatory quarantine had been imposed, found that of the 140 who had recently returned from abroad 75% broke the rules by going shopping, getting mail etc. Most worrying though 40% visited friends away from home and 40% hosted friends and family in their homes. In other words we can’t trust some Canadians to do the right thing and certainly among these high risk snowbird populations we need electronic surveillance as has been done in Asia and Israel
I don’t entirely agree. The only way to get a handle on this virus is to allow for herd immunity to develop. In other words, we actually want enough people to become infected and develop reistance in order to protect the rest. In the absence of a vaccine, we an only do this through infection. What we are doing is ‘flattening the curve’ so our medical systems can cope with the volume of patients coming through at any one time, and also protecting vulnerable populations who are more likely to overwhelm health care resourses as a result of infection and more likely to die of it – an awful outcome for our families and communities.
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