COVID19: Some Quick Q&A part II
by Raywat Deonandan, PhD
Epidemiologist & Associate Professor
University of Ottawa
(I add my credentials to these COVID-19 blog posts in case they get shared. I want readers to know that my opinion is supposedly an educated and informed one)
I have a bit of a busy day tomorrow (and possibly the rest of my life –I’ll explain some other time), so wanted to get in a quick post about some common questions I’ve been getting from the media.
I must say, answering so many public questions has been taxing. I never realized just how exhausting this could be. Here’s a still from my brief appearance on CBC’s “The National” last night. As one friend put it, “You look like you’re ready to spot someone at the gym. That’s a bear-down-and-finish-that-third-rep stare.”
Then you get a newspaper that pulls up a 10 year old file photo of you, looking more like a Bond villain than an epidemiologist. For the record, this photo was taken literally a decade go for a completely unrelated story:
Okay, enough faffing about. Let’s get to the Q&A…
Journalist: “What do we need to do now as we start to lift physical distancing restrictions — how important will timing be in finding fresh outbreaks, how prepared are we to do that, what do we need to know that we don’t know because a lack of real-time data? We imposed the lockdowns in a state of panic – how do we avoid doing so again? “
The goal as we re-open is to be able to identify new cases in almost real time, to prevent outbreaks from becoming epidemics. Outbreaks are almost inevitable, so we need the public health infrastructure to be able to detect them and to be able to descend upon them with overwhelming resources: rapid testing, contact tracing, and the powers to isolate and possibly restrain.
Unfortunately this will likely come at the cost of civil liberties.
To do this properly we will need hundreds of teams of contract tracers, perhaps thousands. The task would be lessened if technology were at our disposal. The new tracking apps, as scary as they sound, are our best bet for rapid low-cost contact tracing. And the arrival of rapid, on-site testing empowers contact tracers to clear potential carriers quickly.
Timing is everything. Every moment after someone becomes infected that they are not quarantined is an opportunity to infect others. Identifying cases in real time goes a very long way toward quashing single cases before they become outbreaks and epidemics.
The risk for Canadians and Ontarians individually is very low. But this has never been about individual risk; it’s always been about population risk. Preventing outbreaks of this very infectious disease is the key to keeping the population safe.
Journalist: “Are we anywhere near able to detect cases in real-time, currently? What are the current barriers? Also, could I ask your thoughts on our initial response? What lessons can (should we) learn from how we responded to the first wave?”
We are near the ability to detect cases in real time, in the form of rapid on-site tests. But we are not able to share that information in real time with the public health authorities. The new upcoming apps might be able to help in that process.
Hindsight is always 2020, and I don’t like to second guess decisions made by people with better information than me. However, 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: mandatory testing and quarantine of all travellers coming from China and Europe, for example, very early on. Preventing travellers from going abroad during March Break could have helped, as well.
But the most egregious oversight was our failure to protect LTC (long term care) residents. It was obvious that this disease would tear through their ranks. It was also obvious that PSWs (personal support workers) working in multiple centres could serve as disease vectors. Our failure to prevent them from moving from centre to centre, and our failure to immediately restrict visitors and to test all residents is inexcusable.
Looking forward, we need better global disease surveillance systems, with coordinated international data sharing. We need a biosciences sector supported and encouraged to be able to quickly create and manufacture tests in the millions, for any new pathogen. And we need a better, calmer public health communications strategy that keeps the public informed of the full plan and the real extent of scientific knowledge so that dissent and misinformation do not spread.”
Journalist (paraphrased): “What is the state of the disease in PEI and what do we now know about immunity?”
PEI is doing extremely well. As of today, you have had 27 cases (of which all have recovered), with 21 still pending. With about 4000 tests completed, your per capita testing rate is about the middle of the pack of provinces in Canada, and the percentage of tests that come back positive is <1%, putting you in an excellent position to feel confident about having captured almost all of your cases.
Moreover, you have seen zero COVID deaths, and amazingly 100% of your cases are clustered among the young or middle aged. As well, 2/3 of your cases are clustered in the Queens region. At this stage, I’d be tempted to characterise your COVID situation as more of an outbreak than an epidemic, and I continue to be bullish about your ability to contain it well enough to comfortably reopen with strong public health measures in place.
As for whether recovery confers immunity, the virus has only been circulating in human hosts for about 6 months, which means that there is no way to know whether immunity (if it exists) lasts longer than that. My reading of the most recent studies suggests that recovery does confer some immunity for most people. But there is some concern that in many people (maybe particularly those with milder symptoms) it will be a tepid, incomplete immunity. We just don’t know. Which is one more reason we prefer immunity conferred by vaccine rather than by infection.”
Journalist: “Numbers of new cases of COVID presented daily are cumulative for that day, and do not separate cases in long term care homes versus cases in the community. Additionally, there was a 7-day lag in contact tracing information.” There followed a four part question:
1. “Whether it makes sense to break down the differences between long-term care numbers and community numbers?”
More nuance in the reported data is always more welcome! Breakdowns by region, age, transmission type, preexisting conditions… these are all useful in not only understanding how the epidemic is unfolding, but also in helping us to direct our scarce resources.”
2. “Are there draw backs to not knowing this? If yes, what issues do you see? If not, can you tell me why?”
I can foresee no scientific drawbacks to having more information. A public management concern is that people will falsely assume that because the majority of growth is in residences that the open communities are totally safe. While the risk in non-residential settings is indeed dropping, we must be diligent in our public health discipline to prevent a resurgent of cases. So anything that might encourage complacency is always to be dealt with gingerly.
3. “Can we be making decisions on reopening based on a 7-day lag in results? What pitfalls might we see?”
Some delay is unavoidable. Perhaps with new tracking technology we might be able to get case data in something resembling real time, but that is unlikely. The challenge is in making resource decisions today about a situation that is likely days old. It’s like trying to point a flashlight at a moving mouse in a dark room. With lagging data, you’re always pointing the light to where the mouse was, not where it currently is.
4. “What would be the best way to present this information, in your opinion? How should we be moving on deciding to reopen the economy?”
Efforts are already underway by disease modelers to incorporate these new complexities of transmission into better models. Instead of assuming everyone is mixing equally with everyone else, these models create separate compartments for LTCs or prisons and account for the different rate of flow of those cases into the greater community count. Knowing the number of cases that are in residences, compared to the community, can help improve those models and make them more precise and useful.
The University of Ottawa’s press office asked for my official stance on Ontario’s re-opening plans. This is my statement:
“The reopening of the economy must be done in a staged manner that is reflective of the best scientific evidence available. With each restriction relaxed, time and effort should be taken to appraise the case data to determine what, if any, effect it has on the epidemic. Only then can we know which steps are truly low risk. As well, any return to pseudo-normalcy must be accompanied by an renewed capacity for overwhelming public health oversight in testing and contact tracing.”
Four questions from a Quebec journalist about that province’s reopening plans.
1. Do you think Quebec has gone crazy/is going too fast in terms of deconfinement?
I understand Quebec’s motivation…. people are economically suffering. But yes, I do think it’s too fast, especially since Quebec is experiencing the worst of the epidemic of all the provinces.
The number of tests coming back positive is about 13%, which is too high. It either means the province is not doing enough testing or the epidemic is still out of control. I would be more cautious.
2. What aspect in particular of their plan is problematic (reopening schools, businesses, allowing visitors in long-term care facilities, etc)?
My biggest concerns are the schools and LTC (long term care) facilities.
LTC residents NEED vistors. But there is a way to make it safe. We could require all visitors to wear high-grade PPE, or even to submit to some screening (temperature checks, medical history, or even a COVID test). This is the one population we should be protecting 100%.
The schools are more difficult. For some time, it was thought that children were very less likely to get the disease and very unlikely to transmit it. BUT some do get it and some do die of it. More importantly, new data out of Germany suggests that children are just as likely as adults to transmit the disease. So if this data is accurate, it means that open schools might allow children to infect their parents and grandparents.
In short, we don’t know enough about the epidemiology and transmissibility of the disease in children to make a proper decision about schools. So I would prefer that we be more cautious.
3. Or is Ontario going too slow?
I think Ontario is going at the right pace. The percentage of tests that come back positive is about 5%. (In Quebec it’s about 13%). This means that we are on track in Ontario to get a better grasp of the epidemic in the next few weeks as that number drops further.
When you go slow, you can check each stage of reopening against the data. For example, we let landscapers go back to work, then check the incident data. Then we let people have dinner parties, then check the incident data. (I’m not saying we should do those specific things, only that they should be done in stages.) This way we can know which policy change caused the changes in the incident case data, and re-assess as we need to.
4, Have you had discussions with colleagues from Quebec? What do they say? Because many experts in Quebec in the media seem to support the Qc government’s approach while experts from English Canada seem to look at Quebec in bewilderment, why?
It’s a good question. No one has any real answers. It’s important to remember that this is not just one epidemic across the country; it’s multiple epidemics happening in multiple regions, each with its own characteristics, culture, resources, and tolerances. So each province should make decisions based upon what it feels its population can tolerate. Though I hope there is some national (and global) strategy for managing borders and the flow of people.
And lastly, here’s a recent phone conversation with my 88 year old father.
Him: “They’re saying I’ll be stuck inside for years!”
Me: “You should ask an epidemiologist.” Hint hint.
Him: “They say this, they say that.”
Me: “If only you knew an epidemiologist you could ask.”
Him: “They won’t give a straight answer about how this will end.”
Me: “Maybe there’s an expert in your family you could ask?”
Nope. Never caught on.
Some Other Stuff
I want to also make sure that you, gentle readers, have at least one good resource to help navigate through these choppy waters. Harvard’s School of Public Health has put together a “way forward” through COVID that some people might find useful. Check it out: https://covidpathforward.com/
That’s all for today, folks. I need some sleep! But I wanted to leave you with a completely non-COVID related message. I’m also an educator, after all, and I’m quite concerned for the educational wherewithal of all my students, and future students, given this interruption in studies.
I got an unusual letter from a high school student who was accepted to our program, but who also wants to study art, and who also wants to be a doctor. They asked the very excellent question of how we support that diversity of interests. I’m pretty proud of the response I gave, so I’m sharing it:
“Thank you for your email and congratulations on your admission!
As a scientist/writer myself, I feel very strongly that all students should try to balance an education in the technical realm (science, math, etc) with the artistic realm (visual, literary, etc). One should seek personal development, not just deep knowledge in a particular set of subjects.
In today’s modern education system, that is becoming increasingly harder. Course selections are getting more and more loaded with discipline-specific content, and I encourage students like you to make maximum use of those opportunities to add breadth to your studies.
To answer your question directly, every program in every university allows (encourages!) students to take courses outside of those that are mandatory for your degree. You will have a handful of credits to “play with” to round out your health sciences career. You can choose to apply those credits toward other topics that interest you, including visual arts, or religious studies, or gender studies, or the humanities, or theatre…. whatever suits your fancy.
In addition, we have a thriving extracurricular community. Students are constantly self-organizing to develop videos, theatrical presentations, or dance ensembles…. all without attachment to a particular course or program.
In short, the extent to which you want to expand your educational experience is up to you. We provide some leeway in the course load. But also you have access to our larger community. Keep in mind, as well, that many of your courses in health sciences might allow for projects that encourage you to express your artistic side. In fact, in 4th year you can pursue an independent research project in the health sciences that might, for example, entail the use of visual arts to address health disparities.
I won’t tell you that our program is better than your other options because I don’t really know what those programs offer. But regardless of where you end up, I encourage you to continue to try to include both your scientific and artistic passions into your educational goals. I’m personally very excited that you want to balance the two.
I hope this has been helpful!”
That’s all for today!