Preparing for the second wave of COVID-19: Discussion

Last week I posted RNAO’s thoughts on preparing for upcoming waves of COVID-19. It is impossible to know for certain if and when these waves may come, or if and when an effective vaccine and access to therapeutics will be available. RNAO has argued since January that we must prepare for the worst and hope for the best. We raised 15 lines of action, many of them interrelated, as part of that required preparation. Keep sending us your feedback, as it is very important and much appreciated! Please write to dgrinspun@rnao.ca and copy my executive assistant, Peta-Gay (PG) Batten <pgbatten@rnao.ca>,  subject line to read: “Feedback on preparing for the next waves of COVID-19.” 

The Ontario government acted on one of RNAO’s recommendations today by requiring bars and restaurants to keep client logs for a period of 30 days so as to facilitate case and contact tracing in case of need.

The federal and provincial governments released today the new Ontario COVID Alert app that will serve as an additional tool in case and contact tracing. This app has been developed taking account of privacy concerns (it does not collect location, contact, health or other personal data) and RNAO is strongly recommending downloading and activating it. Please encourage co-workers, family and friends to do so as well. I already did + RT this tweet!

Our provincial government has not yet acted on the recommendation to implement universal masking requirements across Ontario rather than rely on a hodge-podge of different regulations across various municipalities and regions. We call, once again, on the Ontario government to act – now is the time to keep moving in the right direction.

Thoughtful feedback received from two readers:

RNAO member Erin McPherson writes:

Flu vaccine schedule:

Normally, we don't have access to the flu shot until early November, much later than the schedule in the US where the flu shot is available in September. Normally, I would say that doesn't matter as flu season doesn't really start until late November or early December, but given the real risk of competing viruses, is there any possibility of moving the distribution of flu shots earlier? I imagine that the schedule from development to distribution is already quite tight and thus, altering the timeline may not be feasible, but thought it might help with compliance. 

RNAO response: We agree, Erin, that this year the timetable should be advanced as much as practically possible. I have asked the question from our medical officer of health and will get back to you.              

Masks in schools:

What is RNAO's stance on masks in school? I understand that Sick Kids put out guidance in June stating the masks weren't necessary in schools but I'm concerned that their guidance is already 1 month old in a pandemic that is 6 months old. 

While I appreciate that the recommendations are mixed on the use of masks in kids, there is evidence that the use of masks indoors reduces transmission of the virus without much downside, especially in older kids (references below)

• The National Academies of Sciences, Engineering and Medicine states to "Provide surgical masks for all teachers and staff. All students and staff should wear face masks. Younger children may have difficulty using face masks, but schools should encourage compliance." 
• The AAP recommends that "Children should wear face coverings when harms (eg, increasing hand-mouth/nose contact) do not outweigh benefits (potential COVID-19 risk reduction)" while acknowledging that "Face coverings(cloth) for children in the Pre-K setting may be difficult to implement." 
• Children's Hospital of Philadelphia (CHOP) states "Children are less likely to transmit the virus than adults. Student masking should be prioritized for periods of limited distancing, including: buses, public transit and carpools; hallways or other high-traffic areas; bathrooms; and classroom environments where 6 feet of distance between desks cannot be achieved. More frequent masking may be considered, particularly, in periods of increasing or elevated community spread.” "For young children and youth who are unable to comply with masking, distancing and hygiene measures should be prioritized."

I appreciate the fact that the data is mixed and can only assume that as we learn more, the guidance will continue to evolve. 

RNAO response: As you may know, RNAO has advocated for the use of masks in children three years and older and we run the #Maskhaton campaign to promote their use. We are sensitive to the challenges of having younger children use masks for a full day, so the advice of Children’s Hospital of Philadelphia seems wise. Their advice is similar to a prominent Harvard study that recommends “students wear face masks as much as possible, especially when in hallways or bathrooms.” The revised Sick Kids guidelines recommend masks for high school children but the authors could not agree on recommendations for younger children. The Ontario government’s plan for reopening schools indicates that students from Grade 4-12 and school staff will be required to wear masks.

Batch/pool testing:

Where is Ontario on batch / pool testing? I am reading about approval and use of this technique in other areas and feel like we should be talking about it more. This could be particularly relevant in schools, long-term care, etc., where screening full floors, classrooms and so on – instead of each person separately –, might help prevent outbreaks. Thanks so much for all you are doing to keep us connected.

RNAO response: An explanation on batch/pool testing can be found here. This technique only works in scenarios where the case count is low, so you are right – it fits the current context. I am not aware of consideration and use of batch/pool testing in Canada so thanks for raising it.

RNAO member Timea Andersen writes (we shortened the long message):

I have read this week's letter and, as usual, I applaud the work that you are attempting to do.  There is one part, however, that concerns me. 

With regards to asking government to control the "false health information" being posted on social media, I have intense concerns. What I interpret you to be suggesting sounds like censorship, which is a slippery slope indeed, even with the best intentions.

I was born in communist Eastern Europe and my family immigrated to Canada when I was a child to escape a regime that did exactly that. All other opinions, good and bad were replaced with their own propaganda… Yes, some people do have very misinformed and possibly harmful opinions on any and all possible subjects, but it is not up to the government to decide that. It is up to the reader… 

As a perfect example, it was anti-establishment and absurd to suggest at one point in healthcare history for doctors to wash their hands between patient examinations… There may be some controversial opinions now and in the future which sound incorrect or far-fetched, but at least a few of those may turn out to be cutting edge, ahead of their time, out of the box thinking… We must strive to educate people with the best current knowledge available and hope, not only that the general public chooses wisely but also that the information we now think is the best, turns out to be the best in hindsight…

RNAO response: Thanks, Timea, for raising a crucial issue and helping us clarify our ideas; you are right our writing could be misinterpreted as inviting censorship. You are referring to our item on Fighting misinformation as a public health threat where we say “One of the sad lessons from the debacle south of the border is that misinformation can cause death and suffering on an unimaginable scale. Science and evidence-based information is not a luxury but an absolute necessity if we want to minimize death and disruption to the economy… Government should engage measures to diminish these negative impacts, including demanding that social media venues remove fake and false information on health matters. Governments have sway over Facebook, Twitter, Instagram, WhatsApp, and other platforms that have an enormous influence on health outcomes, and they should use it.”

To clarify our position, we are not calling for government censorship or for government to dictate which views are acceptable or not. The suggestion is that legislators should enact laws that require social media giants to have public accountability and enforce posting standards and ethical frameworks similar to what mainstream media has. This doesn’t silence anyone, but assures there are checks and balances as well as recourse mechanisms when there is evidence of sustained harm. RNAO takes the position that health professionals hold substantive power and should inform that public accountability. That means they must speak with the best available scientific evidence, and caution about damaging health information.

We support freedom of speech, recognizing also that there are limits and constraints to that right. Everyone would agree that free speech does not convey the right to scream “fire” in a packed theatre, when there is no evidence of fire. Does it convey the right to access mass social media platforms indiscriminately to propagate information that science tells us can kill people in the thousands? That’s a thorny question. A nuanced understanding of freedom of speech that reflects our thinking can be found here.