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COVID-19 arrives in Canada

Written by Tristan Bronca on March 9, 2020 for CanadianHealthcareNetwork.ca

Discussed: Canada's public health response, the problem with unknown hotspots, science vs. policy, and the situation in the U.S.

Initial efforts to contain the novel coronavirus—including unprecedented public health measures and quarantines in China, the country of origin—have failed as the virus has now spread to more than 100 countries. While Canada reported a few scattered cases in the previous two months, that number has begun to climb.

As of this writing, Canada’s has nearly 70 active cases, and public health experts are bracing for more local transmission, at which point testing and other public health measures will further ramp up.

Dr. Isaac Bogoch is an infectious disease specialist at the University of Toronto. He’s studied how travel affects disease outbreaks. He spoke with the Medical Post from Amsterdam about Canada’s public health response, the utility and downsides of travel controls, and the emerging issue around the poor containment measures in the U.S.

Q: We spoke to Dr. Allison McGeer at the end of January and she explained that at that point, the odds of getting COVID-19 in Toronto, and I think you could probably extrapolate to Canada generally, were infinitesimal. You’re thousands of times more likely to get the flu. I know that’s changed, but can you explain how much it’s changed?

It’s a great question. I have to start the conversation by saying these are time stamped conversations (Editor’s note: We spoke Friday morning, March 6). We know this is a rapidly evolving epidemic. I completely agree with Allison’s assessment from January, but of course things are different now. In the last 24 hours we have seen an imported case from the United States, a traveller from Las Vegas. We’ve also seen a locally acquired case in British Columbia, which likely reflects some burden of infection here in Canada that’s not being accounted for. 

So, in the coming days and weeks we can expect two things. One, a growing number of imported cases. That means from known hotspots—China, Iran, Italy, South Korea—but also from more places that weren’t previously known to be hotspots. In addition to one from the U.S., it looks like Quebec may have gotten one from India. These places weren’t thought to be exporters of cases. Number two, it’s very likely that we’re going to see more and more community transmission, locally acquired cases in people who don’t have a travel history.

Q: What do you think of Canada’s public health response? They’ve said that they want to try and stave off local transmission for as long as possible. Have they done enough?

At some point the burden of illness in Canada will become great enough that they won’t be able to identify and isolate every case.

This is my personal opinion—I don’t work for Public Health Ontario or Public Health Agency of Canada—but I think they did a really good job. I think the public health lab quickly scaled capacity so they could manage a growing number of cases. To date we have, what, forty-something cases? (Editor’s note: As of this writing, there have been more than 75 total cases in Canada, 68 of which are active.) But there’s been over a thousand negative tests. Each of those people undergoing a test has to be isolated, they need the right test, the test have to get sent to the lab, and the results communicated back to the patient, all in a reasonable timeframe. That takes a lot of resources. So we’ve got a very robust public health system, but at some point the burden of illness in Canada will become great enough that they won’t be able to identify and isolate every case. You can’t do that with influenza during influenza season. There’s no way that we would be able to do that for COVID-19 when it starts to get to more widespread.

Q: So at this point it’s clear that the public health response—with testing and whatnot—has been commensurate with the number of cases that we seem to have in the country?

I certainly believe so. But, did we have an important case that wasn’t detected? Yeah, because it looks like someone who has locally transmitted infection in British Columbia. We don’t know the details, but someone slipped past the goalie at some point. Of course, it’s bound to happen with the number of cases worldwide. It was going to reach a point where they weren’t going to be able to keep up, even though public health is doing a great job.

Q: What happens when more cases start to slip past the goalie, as you say?

We’ll see more community transmission. From a screening and treatment standpoint, we won’t be asking about travel history or contact history when people present with a fever or cough or shortness of breath—we’ll just do the test. We’ll likely see more and more these cases as the weeks go by, just like they are seeing elsewhere in the world.

I’ve heard that the US response is way out of step with the situation. It seems like they have many, many more cases than are being reported.

They’ve really bungled their diagnostics. They didn’t, due to bureaucratic, regulatory and economic factors, they did not scale their diagnostics quick enough and there were too many barriers to screen and those barriers came down too late in the epidemic for a meaningful change. Now they likely have community transmission in multiple places. Maybe they would have been able to stave that off for a few weeks or a few months if they were able to conduct more thorough clinical and public health response through their diagnostic testing. It’s really unfortunate.

Q: How concerning is that for Canadians? 

I think it’s concerning for Canadians for two reasons. One, Canadians travel there a lot, obviously, and they probably have more cases—not just in the absolute sense, because their population is bigger, but even their relative numbers. They likely have a greater burden of infection than in Canada. That’s number one. Number two is, as of yesterday, they started exporting cases to Canada. That’s concerning. Typically we thought of people travelling from China, then China, Korea, Japan, Italy, Iran. Once the United States is on that list…you know, we’re not going to be screening people from the United States. There’s just so much travel back and forth.

Q: At the beginning of this outbreak, public health experts said travel bans don’t work with coronaviruses. Is that evidence still relevant in our current situation, or has that advice gone out the window?

Once the United States is on that list…you know, we’re not going to be screening people from the United States.

There’s science and then there’s policy, right? There’s really decent data to suggest that these travel bans don’t stop the spread of these infections. They just may slow them down by a few weeks, which doesn’t necessarily mean they’re bad. Sometimes people might need a few weeks scale up their diagnostic capacity.

But the travel bans can have a negative impact as well. They can have a tremendous negative economic impact and they can also make matters worse in the areas that are affected by the epidemic. When things are worse in that area affected by the epidemic, it makes it worse globally as well because when people ultimately travel—which they will with or without a ban, people always find a way—it means there are more people with the infection.

So, travel bans don’t tend to work. The optics look good. A country can say, “Look what we’re doing. We have a policy. We’re not having people from that country come in.” But we know that it just slows down the inevitable. That’s exactly what we’re seeing here. While countries and regions may make local policies that doesn’t necessarily reflect what the data says is most effective.

Q: Nurses have raised concerns about inadequate protections for healthcare workers in Canada because there were a bunch of unknowns, they said, related to the virus. I’m wondering if you want to weigh in on that? 

It’s unprecedented at how fast we’ve learned about this virus. We know more about this virus in such a short period of time than any other new infection. We also know how it’s transmitted and how to protect yourselves. The guidelines on how to protect ourselves from Health Canada are pretty clear and pretty effective. For seeing patients, we would use droplet and contact precautions and if there’s aerosolizing procedures we’d use an N95 airborne precautions, with contact precautions. During both we make sure we’re wearing a face shield. I don’t think this is controversial. I’m not going to comment on why some may choose not to believe it, but it’s pretty bread-and-butter, infection prevention and control initiatives.



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