COVID19: Some Quick Q&A Part IV

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 know, I know. These “filler” posts aren’t what you came here for. But I do need a place to archive the responses I’ve been giving to journalists who’ve asked for written comments. So I keep them here.

Thus, today you get a quick summary of some of the nuggets of supposed insight I’ve been arrogantly sharing with those who foolishly think I have something useful to offer.

But first, this tweet from the mighty Dr Carl Bergstrom really resonates with me. I will cogitate upon it whenever I reply to the endless challenges to the mainstream narrative surrounding this epidemic:

Also, I want to plug our most recent episode of the Science Monkey podcast, which was also a special COVID Q&A feature.

Now, tet’s begin….

 

QUESTION #1:

“Do you think it’ll be safe to go back to class in September in Ontario? Is it worth taking the risk for the mental health of kids and their family? Would part-time in-class teaching with 15 pupils per class be better than all students returning to class? How so given that kids touch everything? Should wearing a mask be mandatory for teachers and students in school? Why? Any other precautions you’d recommend for schools?”

MY ANSWER:

There is so much we don’t yet know about how COVID transmits and manifests in children. We do know that children do get it and that they can then pass it on to adults.

We have to distinguish between small children and large children. Those pre-teen and above (>12 years or so) can be schooled in a sufficiently prepared classroom, with small class sizes, mandatory masks and/or face shields, and modifications to their curriculum.

Frequent testing would be nice. But things like temperature screening would be chaotic, as this age group is always getting an infection of some kind, so false positives will be common.

For younger children, mask wearing is probably not viable. Ironically, this is the group that needs classrooms the most, since their social development depends on it.

As well, we can’t open the economy and send parents to work without a place to send small children. So if workplaces are open, then schools must be, as well.

To answer your question directly, I don’t feel we can tolerate keeping small children out of daily social groups for another season. Some accommodation must be made to allow them to go to school. They might include: much smaller class sizes; alternate daily attendance, frequent active COVID screening, frequent hand washing.

And, importantly, there must be a plan in place to quarantine when and if someone tests positive. It would be nice to have services and facilities for those families who are unprepared to send their children to school (those with immunocompromised parents, for example).

 

QUESTION #2:

“Please comment on the US COVID situation and where you think it’s going, and whether Canada might follow suit.”

MY ANSWER:

The crisis unfolding in the USA to me underlines that we are different countries. We have similar (but not identical) demographics, similar language, similar traditions and media consumption, but we are culturally distinct. Canadians seem to value expertise more, are less inclinded to be seduced by conspiracy theories, and, most importantly, are more community minded. Masks, for example, are resisted by a significant number of Americans because masks impinge upon their freedoms. This is less of an issue for Canadians, however, because we properly see masks as a community responsibility for each of us to help keep others safe. This difference in mindset, when scaled up to the national level, results in starkly different behaviours that manifest in different COVID trajectories.

Epidemiologically, the Americans are seeing a trend that we are starting to see in Ontario, as well: the illusion of a decreased disease severity. In Ontario, the case numbers are dropping, but but the hospitalization rate is dropping faster. In parts of the USA, the case numbers are rising, but the hospitalization numbers (with some exceptional states) are not.

This is likely due to three things. First, the nursing home population has already been ravaged; that population is now mostly protected. Second, the elderly are better practised in physical distancing and self-protection. And third, with expanded testing, a greater number of lesser symptomatic cases are making it into the data stream.

With the removal of large number of older people from the case counts, the median age of cases has dropped. The virus has not changed, nor has our relationship to it. What has changed are the demographics of those people mostly becoming infected.

I do not see Canada following in the footsteps of the American experience. Our response has been comparatively consistent, homogenous, and responsible, with most of our citizens acting in proper partnership with the government.

I expect the US situation to continue to get worse for several weeks. Many of their worst hit states are only now starting to enact stronger public health measures, and it’s unclear whether the residents are complying with those measures.

 

QUESTION #3:

“Some scientists have written a letter to the WHO warning that COVID is now airborne. What’s your take?”

MY ANSWER:

First, the great majority of COVID transmission is via respiratory droplets that fall to the ground within 2 metres of the infected person’s face. But there has to be some element of exhalation that is aerosol, i.e. smaller particles that linger in the air longer. Some people have probably been infected that way.

But this is not to say that the virus is floating about all over the place. It’s not in the mailbox or in the park or floating about random buildings. All this means is that if you’re in an enclosed place, there is a greater probability of being exposed if many people are lingering along with an infected person. It doesn’t change what we have to do: wash hands, don’t touch our faces, distance when we can…. and wear masks.

The famous letter sent to the WHO is a policy lever, IMHO, meant to compel the WHO to get onboard with mandatory masks and with making strong recommendations around installing filters in HVAC systems. It does not represent any new scientific evidence or any new requirements for what we regular people have to do.

In other words, don’t worry about. Just keep doing all the stuff you’ve already been told to do.

 

QUESTION #4:

“Please comment on the following aspects of Ontario’s reopening.”

MY ANSWERS:

“1. Are there any developments that stand out to you as being particularly short-sighted, strange or just plain wrong? If so, can you elaborate?”

The early discouraging of mask-usage stands out, of course. I understand why they did it: at the time, we were all stuck in the clinical “masks as PPE” paradigm. It took a new perspective to realize that for most people, a bit of cloth over our mouths and noses can serve as a population-level transmission mitigation tool. This was mostly a federal thing, so I can’t really put that on the province.

Also, the lack of realization or acceptance that this is a pre- or asymptomatic pandemic was distressing. So early decisions to only test symptomatic people slowed our ability to get a handle on community spread.

Lastly, we should have closed the borders immediately. The country can be treated as a virtual island. We should have cut off all sources of new seeding and deal with the infections on our own soil. Again, mostly a federal thing. But the province could have hardened its borders and more strongly discouraged travel.

“2. Are there any developments that stand out to you as being particularly smart, prudent or well-executed? If so, can you elaborate?”

The reopening plan was cogent and responsible, with the right balance of vagueness and detail, and with sufficient caveats to allow for reassessment. Also, Mr Ford was a surprisingly strong and rational presence. Competent leadership is not to be underestimated.

“3. Has the government in your opinion made any serious errors in executing its response to the pandemic? If so, please elaborate.”

As an epidemiologist, I’m focused on data and access to to data. We’ve known for two decades that our infection data collection system is slow and outdated. We had started the process of modernizing it post-SARS, but that got halted for some reason. As a result, we have case details being transmitted from office to office literally by fax machine in some circumstances. The delays in testing and reporting were unforgivable.

Simple things, like opening up commercial and university labs for COVID testing earlier could have hastened the backlog of unprocessed tests. Nationalizing LTCs would have allowed us to prevent workers from cross-contaminating facilities and would have saved lives. Doing active, vigorous and mandatory saturation testing of LTCs and other contained environments would have helped enormously. BC gave us something of a template to work from, so ignorance is an excuse that can be supported only so far.

Failure to prevent international travel during March break was catastrophic. In fact, the encouragement of people to travel exacerbated that error tremendously.

Ontario should have enforced quarantines better. Toronto is a major international travel hub. Yet there were no serious public health checks on returning travellers, just a vague request to self-isolate. Temperature checks and mandatory quarantines might have been useful.

“4. Do you think the government’s reopening plan was well-informed by data and science?”

Federally, the plan was sufficiently vague and rightly downloaded the responsibility to the provinces. Provincially, the response has been more varied. In Ontario, the initial multi-stage plan was fine in that no calendar was given, just objectives. What is unclear is what metrics are being used to drive decision-making. And why some sectors were being grouped the way they were. For example. allowing housekeepers into your home was fine, but you couldn’t visit your grandparent. That was confusing. It seemed that some of the decision making was driven by lifestyle and economic needs more than epidemiologic realities. And that’s fine, but some transparency would have been appreciated.

“5. Overall, how would you rate the government’s response to the pandemic to date?”

I think Ford gained the trust of the province pretty quickly and his “not taking any shit” attitude was useful. He confidently took control early on and clearly was listening to his advisors. Physicians were happy with how quickly he ramped up PPE. Testing and data flow were abysmal for far too long. But They eventually got the former on track.

Frankly, I feel the Premier did well in that he listened to experts and projected a calm and serious demeanour. The problem is that he was not getting the best advice early on. Our failure to protect LTCs, to make testing more efficient, to be more transparent with information, and to provide consistent one-source messaging were astounding and someone needs to be held accountable for those missteps eventually.

 

QUESTION #5:

This was a rude email sent from a member of the public:

“Your comments in today’s Ottawa Citizen about how you think mandatory masks should be implemented now are ridiculous, misinformed and 100% incorrect.

The following scientific research article by 2 of the top infectious disease experts in the U.S.A. will prove that you do not have a clue about what you are talking about. When you state cloth masks are seen as an important “transmission mitigation tool” against Covid-19 you are spewing fake news and misinformation.

https://www.cidrap.umn.edu/…/commentary-masks-all-covid-19-…

This article clearly demonstrates cloth masks are completely useless against Covid-19. I would like you to try and refute the findings in this report.”

 

MY ANSWER:

Despite your disrespectful tone and against my better judgement, I am replying to you. And I will share this reply publicly via my various platforms.

1) You have sent me an opinion article, not a scientific study. Everyone has opinions. What matters is (a) what the scientific consensus says, and (b) the risk-to-benefit-ratio, which tells us what level of evidence is needed to compel action. While every informed perspective is valued, one opinion article is not the final conclusion on a complex issue.

2) This article is 3 months old. New studies have emerged since that are in stark opposition to these conclusions.

3) This opinion article makes the same mistake that many infection control people did at the beginning of this mess: thinking of masks as PPE. This obsession with proper fit, layers of protection, fibre width, etc, is irrelevant when masks are used for population-level transmission mitigation. In other words, this is an epidemiological issue, not a clinical one; and all of this article’s citations and arguments are based in the clinical paradigm and are therefore mostly irrelevant

4) The one intriguing point was that mask-wearing was not effective in Hubei…. but no reference or evidence is given for that statement. What was the extent of mask-weariing in Hubei? Where were they worn? How do they know it didn’t work? The epidemic has been mostly extinguished there, no? Declarative statements require evidence.

5) Almost 100% of cited references are studies of infection rates among health care workers, which is irrelevant to this discussion

6) The thrust of the argument is that non-N95 masks are permeable to the virus. Duh. We all know that. The point of scaled-up mask use is to diminish the *distance* traveled by respiratory droplets, not to actually provide a wall against infection. That they have missed this very basic point pretty much invalidates the entirety of their argument.

7) The best evidence to date strongly suggests mask wearing, when combined with distancing and hygiene, is likely to diminish transmission of this disease substantially

Some references you should read (but won’t):
1) https://www.thelancet.com/…/la…/PIIS0140-6736(20)31142-9.pdf
2) https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.00818
3) https://www.researchgate.net/…/342198360_Association_of_cou…
4) https://www.preprints.org/manuscript/202004.0203/v2
5) https://arxiv.org/abs/2003.07353
6) http://ftp.iza.org/dp13319.pdf

And my post on this issue:
http://blog.deonandan.com/…/covid19-lets-talk-about-masks.h…

Now let me say this bluntly. I am more than happy to engage with the public and to answer questions as best I can. Respectful dialogue is the foundation of a functioning society. You have reached out to me with rudeness, disrespect, accusation, and aggression.

Do not write to me again. Your messages will be deleted without being read.


 

That’s all, gentle reader.  I leave you with this image from the playground near my parents’ house in Toronto. It’s a sad picture, but one that encapsulates this moment in history.

 

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