Preparing for the second wave of COVID-19: What is the plan?
This is a question I have often asked from government officials. Following recent consultations, we are told a plan is on its way, soon to be released. The problem is, the full trust that nurses had at the outset of the first wave of COVID-19 was eroded by the anguish we, and other stakeholders, experienced as we moved for months at a snail’s pace to respond to emerging needs. This is why, as the CEO of the largest professional association in Ontario, and as an engaged leader, I feel it is my responsibility to share our thoughts and invite feedback.
Let me begin by repeating what I have begged government at all levels since January, and in particular from Ontario’s Chief Medical Officer of Health David Williams: We must prepare for the worst and hope for the best. During the first wave of COVID-19 in Ontario, we had it backwards – we hoped for the best, but engaged action late and at a slow pace, thus ending in the middle of the pack. Indeed, while in January the coronavirus epidemic was already full blown in Wuhan, China, followed by major outbreaks in South Korea, Singapore, later followed by gigantic outbreaks in Italy, Spain, New York and other places, in early March our health officials were still musing about “low risk.”
How can we do better as we confront renewed waves of COVID-19, likely starting in the fall? How can we be ahead of the virus when we will likely be confronted with a double whammy involving a concurrent influenza epidemic? Ontario has tremendous talent and is a resource rich jurisdiction. At RNAO we are convinced we can and must do better.
Eager to be ahead of the curve and help inform the provincial plan, we are sharing our thoughts and invite our readers to give us feedback. What is missing? What should be framed differently? How can we better respond, from a policy perspective, to the ongoing challenges of COVID?
Your input is important and much appreciated! Please write to dgrinspun@rnao.ca and copy my executive assistant, Peta-Gay (PG) Batten <pgbatten@rnao.ca>, writing in the subject: “Feedback on preparing for the next waves of COVID-19.”
Preparing for the next waves of COVID-19 – Our thoughts
Although the COVID-19 pandemic is only six months old, we have learned much through failures and successes about its handling. The efforts of both governments and the public have flattened the curve in Ontario and Canada, while enduring a terrible death toll among our elderly, so this is no time for complacency. Experiences elsewhere and the disastrous situation south of the border show the fragility and fluidity of the situation and the continued need for vigilance – a potential new peak of COVID-19 lurks around every corner. Within a short period, we could be facing a vastly deteriorated situation if we make the wrong turn.
Recent epidemiological data in Canada shows variability – the number of daily cases goes up and down and we have seen some upward trend in the reproduction number, remaining for days above 1. There are many signs of public fatigue with COVID measures and lots of irresponsible behaviour, particularly among young adults. There are also serious signs of exhaustion among health professionals. These are not comforting trends.
RNAO insists that we must prepare for a challenging context in the fall, as people move indoors. A recent editorial in Science magazine is entitled Covid 19 and the flu -- A perfect storm, anticipating the prospect of a COVID-19 pandemic and a simultaneous epidemic of seasonal influenza. Each causes life-threatening illness and death, especially in older adults, people with chronic diseases, and other vulnerable populations. The timing and severity of a COVID-19 wave in the fall and winter are uncertain, but past experiences with the 1918 and 1957 influenza pandemics suggest the possibility of a resurgence. Although we don’t yet understand the interaction of influenza virus and COVID-19 within individuals or in the population, we must be prepared for a possible concurrent peak of both viruses, with possible impacts on hospital utilization and in many other ways.
Equity and social justice remain key considerations – these were never given a priority during the first wave, and now they must! The direct impact of COVID-19, as well as the indirect effects resulting from actions required to address the pandemic (leading to job loss, loss of income, eviction, isolation, increased substance use, and exacerbations of mental ailments), affect people in differential ways. While some people are healthy, financially stable, able to work from home, and have good supports both at home and elsewhere, many others are struggling. This can be due to illness and other vulnerabilities, such as crowded housing, financial and personal stresses, loss of work, the challenge of taking care of children at home, caring for the elderly and infirm, exposure to family abuse, the need to go to work in risky contexts, or the discrimination and isolation they face.
RNAO urges government and all of us that for this second wave we must truly prepare for the worse while hoping for the best. We can no longer rely on a message of “low risk,” which was the mantra for far too long at the start of the coronavirus epidemic and even when it became the COVID-19 pandemic. Policies must focus on the elderly and other vulnerable populations – persons experiencing homelessness, shelters, supportive housing, correctional facilities, low-income neighborhoods, and indigenous communities. A policy framework built to address the needs of vulnerable populations must be released soon so that it can be implemented by September in preparation for the challenges in the fall.
We also recommend confronting new peaks of COVID-19 without resorting to extreme measures such as full lockdown and cancelations of surgeries and other critical health services, which are harmful both to the wellbeing of people and the economy. When we went into lockdown in March, we didn’t know better and we required urgent action; this time, there are no excuses. Finding the right path depends on good leadership, science-based policy, and decisive action to implement policies. We also need clear, compelling, and cohesive communication – a critical factor that was hit-and-miss during the first wave of COVID-19. Public health communication was ineffective and confusing. The positive exception was the earnest communication from our Premier starting in mid-March.
It is our association’s view that if we fail to deliver in all these fronts, we may be facing again enormous loss of life. We may also face reversals in the opening of the economy as it is currently happening across the United States. Premier Ford has a chance to come out as a real winner, but he also has a real chance of suffering the political costs of failure.
What follows are RNAO’s policy recommendations to manage and mitigate the next waves of COVID-19 while addressing other priorities. The following items are not ranked – we believe all these policies are crucial and all must be implemented. They are provided under two headings – 1) health policy and 2) leadership, communication, and economy.
RNAO policy recommendations:
Healthcare policy
Implement a universal flu vaccine program for the fall – We don’t yet have a vaccine for COVID but we do for flu, and diminishing the number and severity of flu cases is of major importance for hospitals and other healthcare institutions in case both viruses attack simultaneously. A major public campaign, based on education and health promotion, will persuade people who don’t often get vaccinated, to do so this year. Government must make sure of vaccine availability and address the logistics of distribution and provision, including the required PPE. If there was a year when almost everyone should be vaccinated, this is the one. There should be smaller scale campaigns to vaccinate specific populations, such as the elderly, against pneumonia and other preventable diseases when appropriate. Nurses and other health professionals must be engaged in promoting flu vaccination – we hold the trust of the public and we must support pubic campaigns through social media and other communications.
Mandatory universal masking in transit, indoor and crowded spaces – As RNAO has said repeatedly, the evidence on the effectiveness of masks to reduce the spread of COVID-19 is irrefutable. In RNAO’s view, any further delay in the implementation of mask policies constitutes poor public health policy that is costing and will continue to cost lives and have serious economic impacts. The lack of leadership of the provincial government on this crucially important matter, not making them mandatory, must end. The provincial government should implement a universal masking policy in all indoor spaces outside the home (such as schools, shops and businesses), crowds (anywhere that is difficult to distance from others) and in transit (public transportation), and not leave the decision to cities and health units, which have been the only ones to demonstrate leadership so far.
Keep ramping up numbers and engage sentinel and outreach testing – Although slow in coming, there have been strides in setting up the testing infrastructure as well as increasing test numbers. We cannot rest on laurels -- testing numbers should scale up with an assured 24-hour turnaround in results. We should seek new tests with even shorter turnarounds. There should be accountability on performance, with detailed publicly available data. We need to engage sentinel testing, particularly among vulnerable populations, as well as more specialized forms of testing, such as mobile units, including going to people’s homes, focusing on disadvantaged neighborhoods, persons with disabilities, the elderly, congregate institutions and isolated communities to do on-site testing.
Improve action and accountability on tracing, contacting, and isolating – These actions are central to the containment of COVID-19 cases without them becoming major sources of spread. We have made major gains in these areas, and have much more to do. Public health units across the province are responsible and there has been lack of provincial leadership and accountability as well as heterogenous performance across different units. This must change. The province must set transparent standards as well as a public system of information and accountability, with readily available data in terms of time frames, regions and numbers for tracing, contact, investigation, and isolation. We also need strong procedures to make sure isolation happens as mandated. There should be accountability of public health units on these crucial matters.
Procedures and mechanisms for contact tracing while respecting privacy – The opening of the economy should be accompanied by directives that will facilitate tracing and contacting when clusters appear. This should be the case for businesses as well as public congregations of any type. When COVID-19 cases are discovered, there should be immediate ability to contact individuals who may have been exposed. Given the privacy concerns, procedures developed with the assistance of the privacy commissioner can ensure collected information is used exclusively for purposes of contact tracing.
Data and accountability on PPE – Availability and access to PPE remains a priority. Shortages during the early months of the pandemic drove high rates of morbidity, mortality, and the need for a full lockdown. The shortages of PPE were addressed by drastically shrinking healthcare sectors, such as non-COVID hospitalization and surgery, primary care, homecare, mental and addiction care, dental care, foot care, shelters, etc. The shortages directly factored into the collapse of long-term care resulting in one of the highest death rates among OECD countries – a tragedy of mega proportions. Severe shortages of PPE also caused stress and anxiety among health care workers, in particular in long-term care, home care and primary care. This cannot happen again. RNAO recommends that during the next waves of COVID-19 all healthcare sectors remain open and fully functional, which requires planning for vast amounts of PPE. RNAO has been asking for a six months’ supply of PPE available for every institution and in all sectors. We are told we are making good progress and we applaud it. However, we insist on the need for full disclosure of PPE current status alongside timelines to meet targets. Flu vaccination on its own will create a new demand for PPE. The potential confluence of influenza with COVID would exponentially add to PPE demand. The current provincial and federal approach of remaining opaque and vague in terms of the sourcing, production, demand, supply, and stockpiles of PPE is unacceptable. We require a shift toward full transparency and accountability on matters of PPE so we can all rally and move in unison, protecting health care workers and nursing students, and designated family care givers – across the care continuum.
Data transparency and evidence-based policy – We mentioned the need for increased data transparency in the areas of testing, contact tracing, and PPE stewardship. Issues of fullness and accessibility of data are central to the understanding of the pandemic and the design of effective evidence-based policy responses. This is particularly the case with a novel virus such as COVID-19. In earlier stages of the pandemic RNAO asked for expanded data accessibility, some of which has been provided since then, in areas of comorbidity, social determinants of health, outbreaks in congregate settings such as nursing homes, and excess deaths over normal trends. Comprehensive data collection and data sharing are vital to measure pandemic curve performance, the impact on non-COVID morbidity – such as delayed cancer surgery and treatment as well as longer waiting lists –, prevent and tackle outbreaks in vulnerable communities, and prepare for future COVID-19 waves. The appointment of former federal health minister Jane Philpott as adviser to help with the design and implementation of a new comprehensive health-data platform was an important advance. The expanded EOC Operations situation report is tremendous and much welcomed by stakeholders.
Primary care and home care – These sectors, and others such as community mental health, dental care, physiotherapy, and foot care (the latter especially important for persons with diabetes who, unattended, often end up with infections), either closed their doors altogether or drastically reduced their activity during the first wave. Initially, this was driven by lack of preparation, but a primary contributor appears to be related to shortages of PPE. Practitioners and health-care institutions have adapted to the work in a COVID-19 scenario, but they remain highly dependent on PPE availability. Wherever there has been a shift to virtual care, such as in primary care, these practices must continue, where appropriate, after COVID-19. All healthcare sectors must be prepared to continue their normal work, as much as possible, during the upcoming COVID-19 waves and beyond. Primary care would have been up and running virtually from the outset if OHIP codes set by government in collaboration with the Ontario Medical Association, during the SARS outbreak, would have remained in place. However, they were discontinued. This time around we need those codes to continue permanently. Similarly, codes for nurse practitioners must be expanded. A home-based model to confront COVID-19, such as in the Balearic Islands, can provide tremendous benefits. Now is the time to deploy a community-based model with primary care and home health care in full force! For this, we must secure PPE for these sectors.
Plans to continue with priority surgeries and other treatments in hospitals – The hospital sector successfully weathered the first COVID-19 peak but did so at the expense of stopping countless other hospitalizations, treatments and procedures, which aggravated morbidity and mortality due to non-COVID-19 causes. With more pandemic experience and knowledge, hospitals should catch-up with backlogs as well as prepare to confront the concurrent challenges of influenza and COVID-19 in the fall and winter with minimal decrease of other activity. When other sectors, such primary care and home care, continue to function well, that facilitates hospitals to focus on persons that require hospital care for either COVID or non-COVID reasons. The damage suffered by non-COVID-19 persons during the first wave of COVID-19 is significant, and we have a chance to do better on the second wave – if primary care and home care are fully functioning.
Long-term care – RNAO has provided extensive analysis and recommendations for the long-term care sector. For details, please see RNAO’s demand for a Nursing Home Basic Care Guarantee and for family reunification. Please take action in regards to Minister Fullerton’s July 31 report to the legislature on staffing in long-term care. This is URGENT, as the months of August and September are key to onboard thousands of PSWs, RNs, RPNs and NPs into the long-term care sector before influenza and COVID arrive in the fall. It is also the time to become comfortable with the new model of essential family care partners. As I wrote in an opinion article in the Globe and Mail, we must act now to prevent the loss of an entire generation in long-term care. Now is the time for action, not for a commission and more study.
Other vulnerable and congregate settings – RNAO continues to be concerned about the health and wellbeing of populations that suffer from long term systemic discrimination, marginalization and unequal rights, such as First Nation communities, racialized communities, persons with disabilities, persons experiencing homelessness, persons with mental health and addiction problems, correctional facilities and foreign temporary workers. People within these groups already suffer from lower health status due to systemic discrimination and racism, precarious attachment to the labour market, lower socioeconomic status, a marginalized voice and weaker political representation. They are, consequently, less equipped to defend themselves from the struggles of a pandemic and are at higher risk of contracting the disease with worse outcomes if they do so. The situation of foreign temporary agricultural workers is an example, as they suffer continued outbreaks with direct causal effect to their poor working conditions and their lack of access to basic citizenship rights (such as the right to be sick without being punished with expulsion from their job or the country). In the short run, policies must directly address the specific needs of each social group to mitigate their exposure to COVID-19 and to influenza. At the same time, longer term and structural policies should be engaged to transform ourselves into a more just and compassionate society.
Leadership, communication, and the economy
Leadership and science-based communication as key ingredients in the successful management of COVID – The rapidly accumulating experience of many jurisdictions around the world demonstrates that strong leadership, conveying a sense of common purpose, bringing people together rather than pitting one against the other, coherent and effective science-driven communication, a sense of trust in leaders and institutions, and a capacity to actively engage with stakeholders and provide solutions to problems raised – are all pillars of successful management of the pandemic. In Ontario we have much to improve in this regard. To take us to the next stage, let’s engage a conversation and demand improvements where necessary. Do we perceive our public health officials – in particular, the Chief Medical Officer of Health – to be driven by up-to date science and public health priorities? Are our political leaders, public health officials, Ontario Health and civil servants all singing from the same song sheet? Are they effectively conveying a “together we can do it” attitude to bring all stakeholders on-board? Is public health information provided effectively and coherently? Are various levels of government coordinating their policies and communication? Substantive improvements in these areas are essential and urgently needed.
Fighting misinformation as a public health threat – 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. Provincial governments and the public should take direct action and pressure the federal government to take action to stop the use of media platforms to disseminate harmful information. Every health professional should assume responsibility for responding to damaging conspiracy theories and fake news such as the “dangers of using a mask.”
Fine tune opening-up policies, prioritize schools and stop risky behaviours – RNAO fully supports the slow reopening of our province, as the number of new daily cases remains substantial (an average of 162 during the last week). We also agree with the regional approach to re-opening according to the particular local conditions. Ongoing management of the opening and closing of various sectors and activities will remain critical until there are widely effective treatments and/or an effective and accessible universal vaccine for COVID-19. As long as we remain in a COVID scenario, priority should be given to the opening of sectors based on societal need, not political or economic pressure. The uptick in infections among young adults indicates that specific risky activities should be disallowed, such as indoor bars and indoor parties engaging large groups of people, where alcohol is a contributor to irresponsible behaviour. Instead, priority must be given to other sectors, particularly schools. The health and wellbeing of children and the ability of parents to go back to work must be central considerations. The experience here and elsewhere shows that it is possible to re-open schools with strong health and safety measures. This requires substantial resources and budgets from governments, and they should be provided, as a priority.
Keep the US border closed – As long as the COVID-19 pandemic in the United States remains uncontrolled there should be no consideration of re-opening the border beyond the current flow of essential travel.