From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

Canada’s response to the COVID-19 Pandemic: The August Update (2020)

Sara Allin^1,2, Tiffany Fitzpatrick^2,3, Greg Marchildon^1,2

 ¹ Institute of Health Policy, Management and Evaluation, University of Toronto
² North American Observatory on Health Systems and Policies
³ Epidemiology Division, Dalla Lana School of Public Health, University of Toronto

The COVID-19 pandemic continues to be characterized by significant regional variation across Canada and is concentrated in Ontario and Quebec, the country’s most populous provinces. Over 50% of cases and 64% of Canada’s COVID-19 deaths have been in Quebec; another one-third in Ontario. British Columbia (BC), the third most populous province, is considered a local success story – it experienced COVID-19 early but implemented swift and effective public health interventions. To date, BC has seen only 75 confirmed cases per 100,000 population – Ontario and Quebec have, respectively, reported 272 and 705 cases per 100,000 population.

Many provinces and territories have gone weeks – some months – without new cases; the country has largely managed to contain the spread of the virus. Provinces and territories have gradually re-opened their economies and health systems to varying degrees. While the US-Canada border remains closed to non-essential travel, domestic travel restrictions have been relaxed. Social distancing, testing, contact tracing and – in many regions – mandatory face mask policies are the tenets of re-opening strategies across Canada.

Regional Variations in Pandemic Response

Variations in the pandemic responses across Canada reflect different epidemiologic patterns (some related to international travel and frequent US-Canada border crossings). They also reflect the way public health is governed in Canada, including who has decision-making authority and how effectively they use it. While the federal government is primarily responsible for some public health measures (e.g. international travel restrictions and border control), provincial/territorial governments are responsible for pandemic responses. Taking a closer look at the three most populous provinces (BC, Ontario and Quebec), we see some differences in governance as measured by their communication strategies and use of data to inform decisions. For example, in BC, briefings are daily and done jointly between the top health bureaucrat and senior public health official. In contrast, the premier has played a key role in these briefs in Ontario and Quebec. In Ontario, there are multiple briefings per day with provincial and municipal leaders, which at times has created some confusion and inconsistencies in messaging to the public. Epidemiologic data are released daily in all three provinces, though modeling projections have been updated and shared publicly almost monthly in BC, with only one update (April 20) in Ontario and none since May 22 in Quebec. This suggests reopening strategies have been more strongly justified to the public based on epidemiological data in BC than in Ontario and Quebec.

Current Focus

The focus of decision-makers and the public has recently shifted towards the challenge of reopening schools in September. While there remains much uncertainty around what children, parents and teachers can expect, all provincial/territorial governments have announced schools will open. Most of Canada’s 5.6 million children have not stepped inside the classroom since leaving for the annual March break nearly five months ago.

Further, in recent weeks, the epidemiology of the virus in Canada has undergone significant shifts – the majority of new cases have been reported among young adults. There have been many reports from across the country of youth foregoing public health guidance and engaging in risky behaviors, including large, crowded gatherings and indoor parties with hundreds of attendees. These patterns have prompted some experts to suggest municipalities revise alcohol consumption laws to permit drinking in parks, where risk of transmission is lower.

Moving Forward

Vulnerable populations should and will continue to be the focus for Canada’s pandemic response in the coming months. Residents of long-term care (LTC) facilities have been hardest hit by the lethality of the virus, highlighting the pervasive deficiencies and inequities in Canada’s LTC system as detailed in reports from the Canadian Armed Forces. While the Forces have since left Ontario and Quebec after their deployment to LTC facilities, the Canadian Red Cross will continue to provide assistance in Quebec until September. COVID-19 has also highlighted the need for major reforms in how Canada approaches its LTC workforce – many are precariously employed and underpaid.

Mounting data shows COVID-19 has also disproportionately affected lower income and racialized Canadians. Between May 20 and July 16, 83% of reported COVID-19 cases in Toronto, the country’s largest city, involved members from racialized communities; residents who identified as Black represented 21% of cases despite representing only 9% of Toronto’s population. Another area of concern is ongoing outbreaks of COVID-19 among migrant workers. Canada’s agricultural and fishery sectors rely heavily on highly trained seasonal workers.

Data collection and rapid responses to these disparities will be key to ensuring equitable re-opening strategies across the country, particularly as more Canadians return to work and school in the coming weeks. Timely and detailed data will be critical to informing evidence-based approaches and will support lesson-learning from the successes (or failures) of other provinces, territories and countries.

Canada’s response to the coronavirus pandemic: Update (May 2020)

Sara Allin^1,2, Greg Marchildon^1,2 and Karen Born¹ 

¹ Institute of Health Policy, Management and Evaluation, University of Toronto
² North American Observatory on Health Systems and Policies

 

In the month since we wrote the Canadian piece for this series, the number of confirmed cases of COVID-19 have nearly quadrupled (15,500 to 61,810 from April 5-May 5), and total number of deaths increased seventeen-fold (231 to 3,980). The experience in Canada is considered “a series of regional epidemics” owing to wide variation in the spread of the virus. For instance, Ontario and Quebec both have significantly higher cases and deaths than in British Columbia (BC). BC, in part owing to outbreaks in neighbouring Washington State, was able to implement a broad public health response to “flatten the curve” much earlier. Some of the Atlantic provinces brought their daily new cases to zero, and the territories in the far north have had little to no spread to date.

Relative to other countries, Canada has succeeded in containing, but not eliminating the virus. It has avoided overwhelming the health system and the magnitude of the death tolls as experienced in Italy, the United States and the United Kingdom. There has been a gradual slowing of the rate of increase of cases in Canada: cumulative cases were doubling every 15 days at the end of April compared to every 5 days at the beginning of April. On May 5, the per capita confirmed COVID-19 cases in Canada were 1,610 per million people compared to 2,807 in the UK and 3,567 in the US. Deaths per 100,000 population were 10.5 for Canada as whole (26.8 per 100,000 in Quebec) on May 5 compared to 21 for United States (129 deaths per 100,000 people in New York – the state with the highest cumulative deaths per capita). However, the number of new cases in Canada has not begun to decline overall.

As provincial governments start to relax their public health measures and re-open businesses, public spaces and non-COVID-19 hospital care such as surgeries, there are a number of pressing concerns facing Canada in the short-term. These include the continued concentration of outbreaks and mortality in long-term care (LTC) facilities, the limited capacity for widespread testing, and case and contact management and tracing, the threat of spread from domestic travel, in particular from the hardest hit areas in the United States, and the unintended consequences of the economic shutdown.

The COVID-19 pandemic continues to disproportionately affect vulnerable populations. These including residents of LTC facilities, other supportive congregate housing, certain high-risk workplaces such as meat processing, and more recently, northern indigenous communities living on reserves. The hardest hit, to date, are the residents in LTC facilities; across Canada, COVID-19 deaths among LTC residents make up about 66% of all deaths, and in Ontario, estimates are even higher at over 80%. Quebec and Ontario are most affected, with the Canadian Armed Forces providing support. While there have been a number of measures introduced to protect LTC staff and residents, such as increasing wages, limiting movement of staff across sites, and expanding testing in LTC facilities, these have been widely criticized as coming too late. This pandemic has revealed fundamental weaknesses in the financing, regulation and management of facility-based LTC in Canada.

In spite of increased capacity for the testing of individuals, there continues to be a limited supply of equipment and workforce needed to reach all high-risk groups. We are far from achieving widespread community testing that may be needed to reduce the danger of reopening. Testing has increase significantly from about 9 tests per 1,000 Canadians on April 6 to 26 tests per 1,000 on May 6; these still fall short of provincial and federal targets. There is no data to assess the extent to which we’re reaching the target of contacting and tracing 90% of new COVID-19 contacts within 24 hours. We continue to rely on traditional approaches to contact trace, testing the limits of an already overstretched public health workforce. There has been some limited take-up of new technologies for contact tracing, such as a new app in Alberta, but these raise concerns both about the efficacy of these tools as well as ethical questions about privacy and the appropriate use of the data.

There continue to be major concerns owing to the unintended consequences of the restrictive health system and public health measures. These include a major backlog in elective surgeries, primary care and associated diagnostic tests, prescription drug therapies and referrals to specialists. These are longstanding challenges in Canada that have been exacerbated since the pandemic. We also need to pay attention to the as yet unmeasured impact of unemployment and economic shocks on health in the short and long-term. The most recent estimates reported close to 20% unemployment in April, with disproportionate impacts on women and recent immigrants. These numbers will have worsened since then. It remains to be seen whether and by how much the wide array of provincial and federal economic protection measures will mitigate these health and social impacts.

Canada’s response to the COVID-19 Pandemic – Original post (April 2020)

Sara Allin^1,2, Greg Marchildon^1,2 and Karen Born¹
 

¹ Institute of Health Policy, Management and Evaluation, University of Toronto
² North American Observatory on Health Systems and Policies

The first case of COVID-19 was confirmed on January 25, 2020 in Toronto with a recently returned traveler from Wuhan, China. The number of cases grew slowly throughout February (mostly from returned travelers from international hotspots), then at an increasing rate through community transmission. On April 5, there were over 15,500 confirmed cases in all 10 provinces and in 2 of Canada’s 3 territories.

As a highly decentralized federation, public health measures are the shared responsibility of federal government and provincial and territorial (PT) governments. In addition, PT governments have delegated some public health responsibilities to regional and provincial health agencies. Local governments, particularly those in the larger cities, also exercise some public health responsibilities. Thus, there is some variation in the timing, intensity and range of measures taken across the country, and coordination is of heightened importance in this outbreak.

The first official communication from the country’s most senior public health officer was on January 20, at which time it was announced that the risk to Canadians was low, and some limited screening was added for select travel routes. Until mid-March, the primary focus of public health measures was on international travelers returning from Hubei province, and subsequently additional affected regions. While there were strict quarantine measures for select travelers (starting Feb 3), public health measures in these early stages of the epidemic in Canada were mostly reliant on voluntary self isolation for those returning from travel, as well as health communication (e.g., washing hands, coughing into sleeves, monitoring symptoms). On March 13, right before most provinces’ spring break from school, the federal government advised all Canadians to avoid “non-essential travel” abroad, especially to high risk countries with level 4 travel advisory which did not include the most common international destination for Canadian travelers – the United States (U.S.).

Measures increased in intensity after the WHO declared the outbreak a pandemic (March 11). A day later, Prime Minister Justin Trudeau went into self-isolation after his wife Sophie Trudeau tested positive for COVID-19 following travel to England. As cases were increasing more rapidly, PT governments started declaring states of emergency, granting them powers to use land and human resources, to secure supply chains as needed to prevent or respond to the epidemic. Between March 13 and 22, all PT governments declared a state of emergency, and announced school closures.

The federal government closed the border to foreign nationals for all “non-essential travel” on March 18. The U.S. was exempt until March 21 when both countries agreed to close the border with the exception of essential travel (transport related to food, fuel and medicine). On March 25, under the Quarantine Act, the federal government mandated a 14-day self-isolation for individuals entering Canada, whether or not they have symptoms of COVID-19. Domestic travel restrictions were introduced on March 30, whereby air and rail operators are expected to screen travelers for illness.

There has been a massive investment in health systems and the economy. Health system capacity is a major pressure point. With many hospitals already operating at or above 100% occupancy rates, there have been significant efforts to divert patients from the hospital sector. This has been through a number of measures to shift health system supply and demand dynamics such as expediting transfers from hospital to long-term care (LTC) facilities when appropriate. Further, PT health systems reduced and then subsequently cancelled all elective surgeries. Much outpatient and elective care has rapidly transitioned to virtual care, such as by introducing temporary virtual care billing codes. The federal government invested $500 million for PT health system efforts, and each PT also invested a significant amount (e.g., CA$3.3 billion in Ontario). Testing falls under PT jurisdiction, so testing criteria and turnaround times vary, but limited supply of test kits has led to the use of fairly strict testing criteria across the country, with no deployment of community testing of people without obvious COVID-19 symptoms. FPT governments are making efforts to increase supply of human resources, test kits and other medical equipment where there seem to be shortages- notably personal protective equipment (PPE) and ventilators.

What has gone well?

The recent use of strong measures by FPT governments, both in terms of containing the spread of the virus, and in protecting Canadians from its negative economic impacts (including a federal government investment of CA$100 billion) have been well received. Also, there has been strong PT public health leadership. Several innovations have rapidly been adopted and scaled up in the health system, reversing decades of stagnation in many of these areas (e.g., with virtual care, new technology to address medical supply shortages, and expanded scopes of practice to bolster the health workforce). There are also some signs, in particular in B.C., that the public health interventions have had some success in flattening the curve of COVID-19 incidence, though this has not yet been demonstrated in Canada’s most populous provinces (Ontario and Quebec).

What challenges does Canada currently face?

The experience with COVID-19 in Canada has exposed some weaknesses and revealed new challenges. Challenges reflect an already constrained health system with some of the lowest levels of hospital beds per capita in the OECD. In some provinces, the LTC sector is under-resourced and has persistent staffing and personnel gaps which are fostering transmission in this setting. Deaths of LTC residents comprise more than half of all of Canada’s COVID-19 deaths as of April 5.  Persistent health inequalities in Canada may be exacerbated if significant protections aren’t put in place, since vulnerable populations such as those experiencing homelessness and remote Indigenous communities face higher risks. Moreover, there are challenges with coordination across FPT governments in both data sharing and surveillance, and in policy interventions. This continues to be a challenge, and one that has potentially significant health implications, for example, if PT governments relax their measures at different times. Finally, the constant flow of goods and people across the southern border with the U.S. will likely undermine domestic efforts to contain the virus as the U.S. accounts for a quarter of cases of COVID-19 globally.

Predictions for the future

We expect that Canada will continue with these (recently introduced) strong measures of border closures, physical distancing and states of emergency into summer to contain the impact on the health system and minimize deaths. The significant backlog from canceled surgeries and reduced health system contacts could have benefits if Canadians embrace virtual care, and consider what services and care were previously unnecessary. However, the impact of delayed care and surgeries may exacerbate already long wait times for years to come. Typically under-resourced sectors, such as LTC, will either receive injections of financial and human resources support or experience diminished quality of care and services due to COVID-19.

In future, FPT governments and their respective public health agencies will likely create more effective vehicles for pan-Canadian coordination and the sharing of information as well as mechanisms to deal with any potential policy conflicts concerning access to needed medical equipment and interprovincial transportation of people, goods and services. This crisis may also have opened a window of opportunity for major policy action, such as coordinated supply chain for essential goods such as PPE and essential medications, as well as serious consideration of a guaranteed minimum income to replace the numerous federal and provincial income support programs that currently exist.

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