COVID: Revisiting Public Health Protocols

 

COVID: Revisiting Public Health Protocols

--by Stewart Vriesinga, January 18, 2021

In a dynamic situation, when the pandemic, the science, and even the virus itself are rapidly evolving, clarity seems elusive. That old saying “If you can keep your head in all this confusion you just don't understand the situation” seems apropos. This essay is my attempt to sort through some of that confusion and all the conflicting assertions we are hearing from so many different quarters.

Ontario has again declared a state of emergency. Hospitals are quickly becoming increasingly overwhelmed. Not only is there a shortage of ICU beds, but also a shortage of medical staff to look after the patients who occupy them. Medical staff is now being advised to triage patients based on, not the severity of their illness, but rather on the likelihood that they will recover; ventilators will be reserved for those most likely to recover in the shortest period of time. Additionally, since existing measures had proved to be woefully inadequate, a new list of restrictions and protocols have been drawn up to slow down the spread. But will they work this time?

If they do work we can expect these restrictions to be eased and eventually lifted when the numbers of critical cases have been reduced to a level deemed to be low enough for the healthcare system to cope with. If, when, and even whether or not the numbers come down is contingent on a number of factors. Let's take a closer look at some of those factors.

First and foremost, it is important to understand that, while the stated and primary objective is to reduce the spread of the virus, there are clearly additional political and economic considerations. Government decision-makers may indeed be creating policy in consultation with at least some medical health experts, but they are also very reluctant to close down more of the economy than is absolutely necessary. Many of their constituents –and to a large extent their political support base--are more concerned with the economic hardships caused by the measures used to control the spread than with the spread itself. Consequently governments are often very slow to respond to the repeated and increasingly dire warnings and pleas of non-governmental healthcare professionals. When they do finally take action and introduce additional restrictions, the actions and restrictions are often based on overly optimistic expectations about the efficacy of the new measures. As we have seen in the past, the number of infections and number of deaths continue to rise despite government mandated protocols and restrictions. But did they get it right this time? It depends on who you ask.

Furthermore, some protocols and restrictions seem to be more about creating a false public perception that decisive action is being taken than with actually slowing the spread of the virus. In this essay I will examine some of the measures already in place more closely, and try to parse out those which seem to be more about placating an increasingly alarmed public from those which will actually help reduce the spread to manageable numbers. More on that below. First I want to look at some other pertinent issues: public confidence in the measures being taken; testing, contact-tracing, and asymptomatic spread; vaccines; and the complete failure to take into account the horrendous implications of the new variants of the virus that continue to appear are having on the rate of spread. 

PUBLIC CONFIDENCE:

Compliance with government protocols depends largely on public perception of those protocols. In the past we have seen that many people think these protocols and restrictions are unfairly targeting some businesses while inexplicably exempting others. Many businesses which have implemented many of the previous protocols and recommendations –enforcing the wearing of masks, sanitizing surfaces, installing plexiglass barriers, taking employee temperatures, etc.--feel their businesses present a lesser threat than other businesses which are allowed to remain open. Consequently these businesses see the closure of their businesses as relatively ineffectual and/or unnecessary. Similarly, the government has failed to explain why there are ever greater restrictions on social and family gatherings (the latter now limited to five), while workplaces in which dozens if not hundreds of people intermingle every day are allowed to remain open. Yet governments –especially Premier Doug Ford here in Ontario—tend to attribute the escalating spread almost entirely on individuals' failure to stay home, stick to their bubbles, wear masks and forego all social interaction and gatherings. Portraying and treating thinking adults as if they were disobedient petulant children may deflect attention away from workplace spread and failure to regulate and/or properly staff LTC homes etc., but is not likely to bolster public confidence in government leadership. The notion that having a family bubble in excess of five people is irresponsible must, quite frankly, seem totally absurd to employees with no other income who are forced to run the gauntlet and intermingle with hundreds of potential carriers on a daily basis, while forcing their own children to run similar gauntlets in the schools.

That said, ostensibly many people still have total confidence in all the protocols, restrictions and recommendations that the government has put in place and, instead of questioning the efficacy of these measures, place all the blame for the continued escalation of the spread entirely upon those who fail to follow the protocols, and on lack of enforcement.

TESTING, CONTACT TRACING, AND ASYMPTOMATIC SPREAD:

From the beginning it was clear that testing is key to getting this virus under control. Its very presence wouldn't have been confirmed without testing. The identification of those infected, followed up by contact tracing, the quarantining and contact tracing of infected contacts, etc. was how we were going to stop the spread. Testing was also the only way of determining the rate of spread. Initially we lacked the tests themselves, the PPEs to safely carry out tests, the personnel to do tests, and the laboratories to analyze those tests and come up with results; we couldn't really do much testing. Given these limitations the focus was initially on testing only travellers who displayed symptoms and those they had been in close contact with. Testing was later expanded to include others who also displayed symptoms. As PPEs and tests became more readily available more testing was done, but because resources were still limited, only people who showed symptoms and/or people who had been in close contact with known positive cases were tested. Contact tracers, also in short supply, were deployed to trace down all the people who had been in close contact with a known carrier so that they too could be tested and, if positive, quarantined, and, if necessary, treated. The majority of those testing positive only showed mild symptoms, so instead of being hospitalized they were told to self-isolate at home. Since community spread was not a major issue for the first month or two it was assumed that the focus should be on travellers and those they had been in close contact with.

Positive cases that could not be traced back to travel (in retrospect probably caused by undetected asymptomatic and pre-symptomatic carriers), made it clear that the inevitable community spread had become a reality. People who had no travel history, and had not knowingly been in contact with a known carrier, became concerned and wanted to get tested to make sure that they weren't inadvertently passing the virus on to more vulnerable loved ones. However, due to rising cases and limited testing and tracing capacity, anyone presenting themselves for a test who was not displaying new symptoms was refused. Initially it was presumed that once capacity had been sufficiently increased an aggressive program of broad-based universal testing of the general population would be launched. That never happened. Often people have to wait for days to get test results –too long for effective contact tracing needed to identify, locate, and test all known contacts of each and every positive case. Coupled with the shortage of contact-tracers, delays in test results eliminated any possibility of tracing down all sources and stopping the spread. Many sources were never identified, and most spread was vaguely attributed to community spread.

Furthermore, because as we now know more than half of all carriers are either asymptomatic or pre-symptomatic (24% and 35% respectively), roughly half of those spreading this virus weren't/aren't even known to be spreading it. By itself the omission of all these carriers is enough to scuttle any plans to curb the spread. But it didn't/doesn't have to be like this.

In addition to dramatically ratcheting up testing and contact tracing capacity, wastewater testing could have been and should still be implemented in every wastewater treatment plant in the country. While wastewater testing cannot identify individual carriers, it can serve as an early warning system to show where COVID 19 is present, the rate at which it is spreading in a given community, and the different variants of the virus involved. (More on variants later.) All the information gleaned from wastewater testing could and should be used to determine where people are most at risk, which in turn would help authorities decide where additional testing, resources, and restrictions are most urgently needed. 

 

VACCINES:  

The development of vaccines has raised the hope of an imminent end to both the public health crisis and the economic crisis spawned by the pandemic. In a few short months herd immunity would be achieved and things would go back to normal. The first inoculations have already happened, and more will soon follow. Salvation is at hand! A collective sigh of relief could be heard throughout the country. Business owners looked forward to being able to reopen their business and respond to all that pent up consumer demand; restaurants would once again flourish, as would hotels and the tourist industry; children learning online could go back to school; stadiums would fill up for sporting events and concerts etc.; unemployed workers could return to work; and grandparents could once again give and receive hugs their from grandchildren.

However there are a few flies in the ointment. Overwhelmed hospitals and an alarming ongoing exponential escalation in new cases and rising death tolls mean that we cannot sit on our laurels for two or three months until herd immunity is finally achieved. The most vulnerable are more vulnerable than ever, and further sacrifices must be made to protect them. The roll-out of the vaccines will be subject to delays while Pfizer expands its plant in Belgium. And many Canadians don't trust the vaccines enough yet to get themselves inoculated, which may be a barrier to herd immunity. And, if that weren't enough, new variants of the virus have emerged that are far more contagious, and will result in even greater acceleration of the spread and much higher death tolls, necessitating even more stringent restrictions and lock-downs.

When the fat lady cleared her throat just now, was that really because she's getting ready to sing? Or was that a symptom indicating she too has caught the virus?

IMPLICATIONS OF THE NEW VARIANTS OF THE VIRUS:

None of the new emergency measures to date seem to have taken into account the horrendous implications of the arrival of new variants of the virus. Variants that are already on the loose in the community, and cannot be traced back to a few isolated cases of travel. The failure to plan for this contingency is a major error. It will result in the most dramatic rise in spread that we've seen to date. There is speculation that a new COVID outbreak in the Roberta Place Long-Term Care Home in Barrie was caused by a variant of the virus. Global news reports that 43 staff and 62 residents were infected. Nine residents died. That tragedy may be harbinger of what awaits us in the coming weeks.

Such a huge escalation in the transmission rate was foreseeable and avoidable. Yet there has been no planning for such a contingency. For over a year now it has been obvious to all and sundry that LTCs have suffered from a lack of oversight, regulation, and neglect. Unannounced regular inspections had long ago been abandoned in favour of complaint-based inspections only; homes were often found to be in violation of the very same regulations repeatedly, without consequences or corrective action. Despite the pandemic bringing all this to light and all the media scrutiny almost a year ago, very little has changed. If anything vulnerable residents and staff are more vulnerable than ever!

But that is not all. The arrival of more contagious variants of the virus should not have come as a surprise to authorities either. In fact the scientific community had anticipated and even sequenced many of these mutations before they actually happened in nature, including the different ones that were first identified in the UK, in South Africa, and in Brazil. Canada does very little testing period, and most of the testing that it does do cannot distinguish between the original virus and the far more contagious variants that are now emerging and will soon become dominant. While these new variants are not more deadly than the original in the sense that someone infected by one of the new ones is not more likely to die than someone infected with the original, they are more deadly in the sense that thousands more will die from them because thousands more are likely to become infected. Yet authorities have not come up with a plan to deal with the variants that the scientific community has been warning about for months.

And, as if all that weren't enough, there is a strong possibility that antibodies resulting from previous exposure to the original virus, or by vaccine inoculations, won't be as effective on some of these new emerging variants. For instance there are some questions about whether or not the variant that emerged in Brazil will be neutralized by existing vaccines. If that does prove to be the case new broader spectrum vaccines will be required. I'll leave it up to the reader to ponder the implications of that...

PARSING OUT PROTOCOLS:

It is my contention that some Public health COVID 19 protocols are far more effective at reducing the spread than others. I'd like to parse out some of the protocols that are most likely to be effective in reducing the spread from those which seem to be more geared toward mollifying an alarmed public without shutting down the economy and further infuriating the business community. It is not my intention to come up with a comprehensive list of all protocols and go over each of them one by one, but rather examine a sampling of protocols and analyze them in terms of their effectiveness in curtailing the spread, and in terms of their likely impact on the economy and how palatable they might be to the business community. Some protocols, of course, serve both purposes. Others are better understood in the context of dual, often conflicting, objectives; namely the dual objectives of reducing the spread of the virus, and minimizing the impact of the pandemic on businesses and the economy.

It should be noted that these protocols are put into place as packages. Some protocols in a package may be more acceptable than others, regardless of which objective one prioritizes. This is not lost on policy makers. For instance, businesses may be willing to implement mask protocols, install plexiglass shields, and sanitize surfaces if doing so allows them to stay open. As I will elaborate on below, the wearing of masks has been shown to be effective in reducing the spread; the installation of plexiglass and the sanitation of surfaces has not. Nevertheless a business complying with this set of requirements is complying with three out of three protocols. The two protocols relatively ineffectual at stopping the spread do nevertheless help create a public perception that the business is relatively safe and therefore shouldn't be shut down. Let me cite a couple of other examples to further illustrate this point:

I'm a school bus driver, so I'm quite familiar with public health policies around the transportation of school children during a pandemic. When schools were reopened last September there were a number of workplace recommendations intended to keep everyone safe. In some ways the recommendations were very similar to those being made to the schools. These included masking of children from grade four and up; social distancing, cohorting, frequent sanitization of surfaces, daily self-assessment to prevent those showing symptoms from potentially infecting others; good ventilation; etc. Implementing these protocols was not always practical in all situations. When it was impractical protocols were often either relaxed, or waived altogether. Of the six protocols listed above it was decided to drop the physical distancing requirement, both in schools and on buses, not because the science didn't support it, but because the cost was prohibitive and the resources simply weren't there. On school buses compliance would have required tripling the number of buses as well as the number of drivers. In schools compliance would have required more classrooms and the hiring of more teachers. It was more expedient to combine existing classes so some teachers could be reassigned to online instruction for the work-from-home students. Other protocols like good ventilation were relaxed. Weather permitting, windows could be opened on buses and also in classrooms whenever possible. Classroom cohorts were set up in schools, but were infiltrated on a daily basis by students who rode the bus –a bus operating at full capacity (72 children), servicing as many as six or more different schools, each transporting students from dozens of family bubbles, ranging in age from junior kindergarten to grade twelve. Parents who had been deluded into thinking they could avoid the perils of having their children riding a school by driving their children to and from school were just that –deluded into a false sense of security. Each of their children's classroom cohorts were being infiltrated by several bus riding students every day. The self-assessment protocol, while not removed, was watered down. Not only did pre-symptomatic and asymptomatic children continue to attend classes; children displaying only one symptom were also encouraged to attend.

It must also be noted that schools themselves play a dual role: not only do they provide an education for children; they also provide the only form of affordable daycare for front line service sector workers, not to mention options for parents experiencing difficulty in overseeing their children's online education while simultaneously trying to work from home themselves. The former –service sector workers-- comprise the workforce of the largest sector of the economy. Governments have an economic incentive to keep schools open that may outweigh the risks –ensuring a supply of low wage workers to service sector industries. Denied paid sick leave, E.I., or any other sort of income, service sector workers whose children could attend school had to return to work regardless of risk if they were going to put food on the table and pay the rent.

On the topic of risks, I think a reassessment of risks is also overdue. Like the virus itself, scientific knowledge of the virus is also evolving. Protocols should be based on up-to-date science, not what we though we knew about the virus a half-year ago. We now know that there is little scientific evidence to support some of the protocols that are still in place, not to mention some of the new ones. Inversely there is relatively new and compelling evidence about forms of transmission that are still largely being ignored. Let's examine some of them:

• Fomites: There is very little scientific evidence for transmission via fomites –contaminated surfaces. For the most part the fastidious sanitization of surfaces only places additional unnecessary burdens on those who must carry out the task, without significantly reducing transmission. The practice may instill a false sense of security in clients and bus-riders, and provide businesses with an excuse for staying open, but most of the remains of viruses found on surfaces are effectually dead –they're incapable of contaminating anyone.

• Plexiglass: While plexiglass shields and face-shields may prevent larger droplets from landing on and infecting a bystander, most transmission is due to aerosol –microscopic airborne droplets that stay suspended in the air for a considerable length of time.

• Airborne transmission: Airborne or aerosol transmission is the primary form of transmission. It occurs indoors, especially in a large enclosed poorly ventilated space. Unlike the larger droplets, which usually fall to the ground within six feet of the transmitter, microscopic airborne droplets can stay suspended in the air for a considerable length of time, and will infect everyone present if they inhale enough of them. People entering such a space can become infected even if the original source is no longer present. When such transmission occurs in a crowded space infecting many people it is usually referred to as “a super spreader event”. Workplaces, second only to LTC homes, are the primary places where most airborne transmission occurs. Let's treat them as such. (Meat-packing plants, factories, warehouses, migrant living quarters on produce farms, etc.)

• Outdoor transmission: With the possible exception of crowded spaces or lineups with no breeze whatsoever, outdoor transmission rarely occurs. There is no scientific basis for limiting outdoor meetings to five people or less.

• Masks: Masks have proven to be a very effective way of reducing transmission. The wearing of masks should be required and vigorously enforced.

• Closing of Borders: Contrary to public perception, the borders have not been closed. Land borders have, except for the transport of essential goods.  But non-essential international travel still occurs at airports. It shouldn't. Before travelling all international air travellers should be required to obtain and present a special permit justifying their trip based on similar criteria as over-land travellers. Upon return they should quarantine themselves at their own expense, but under strict supervision.

Again, this is my no means a comprehensive list or evaluation of all existing and past protocols. As I have eluded to above, additional protocols in response to delays in vaccine roll-out and the emergence of new variants of the virus are urgently needed. I will leave it to readers to evaluate protocols not mentioned here.

SUMMARY AND RECOMMENDATIONS:

Strategies to reduce the spread and contain the virus should be completely divorced from all other political and economic considerations. Until such time as the threat to public health is overcome the focus should be singularly on public health. This can only be achieved by setting up a non partisan special task force comprised of epidemiologists and other healthcare professionals charged with setting up all protocols, restrictions and closures related to this pandemic. Public money should be used first and foremost to protect the most vulnerable, front line workers, all those facing an existential threat because of this pandemic, and to look after the sick and dying. It should not be used as corporate welfare or economic place-holders for corporations and small businesses that have become nonviable because of the pandemic. Given the global nature of the pandemic many businesses could remain nonviable for years to come. If anybody is going to be on life support it should be a human being, not a business with a questionable future. Public money disbursed during this pandemic should never end up in peoples savings accounts, nor be used to pay out dividends to shareholders or bonuses to CEOs. Any assets of corporations or businesses should be sold before they are entitled to pubic funding. The inequities that has left so many extremely vulnerable during this pandemic should be reduced, not increased. An economy that replicates the pre-pandemic distribution of wealth and power, with all its inequities and injustices, is very unhealthy and does not deserve to be considered recovered.

Finally, economic recovery, whatever form it takes, cannot and will not happen until we all get past this global pandemic. Let's keep the focus where it belongs –on public health!