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.