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Is Ontario ready for a second wave of COVID-19?

Posted: September 9, 2020

(September 8, 2020)

By: Joanna Frketich & Grant LaFleche, St. Catharines Standard

“Disaster upon disaster” is how the Registered Nurses’ Association of Ontario describes long-term-care homes during the pandemic.

“Nursing homes basically during COVID-19 for several months were abandoned,” said CEO Doris Grinspun. “Abandoned by government in very concrete ways.”

Despite promises from the federal and provincial governments to end long-standing problems that led to long-term care and retirement homes becoming the epicentre of COVID-19, accounting for at least two-thirds of Ontario’s pandemic deaths, Grinspun says little has changed as Ontario prepares for an expected second wave of the virus over fall and winter.

“It will be one tragedy on top of another tragedy,” she said. “I basically am afraid we will finish a whole generation of seniors in nursing homes if we don’t do something fast.”

The lack of progress in properly staffing, overseeing, modernizing and funding long-term care raises questions about whether Ontario is prepared for the second wave of COVID-19. Will seniors’ homes be the epicentre again? How will Ontario’s normally overcrowded hospitals cope? Will the public even know about outbreaks in businesses and workplaces? How do Ontarians know what risks are worth taking as the province reopens?

“Nobody knows when that second wave will hit or how bad it will be,” said Dr. Dominik Mertz, associate professor of infectious diseases at McMaster University. “We will see what happens when fall and winter comes.”

Most Ontarians fear the second wave, according to a poll commissioned by the Canadian Mental Health Association. The vast majority expressed worry people are becoming relaxed too quickly and not following physical distancing requirements, found the survey of 1,002 Ontarians conducted by Pollara Strategic Insights from July 23 to Aug. 2.

Nearly 80 per cent are concerned the province will go back into lockdown and 85 per cent dread a second wave will “put us back where we started.”

“Even when things are going well, there might be a turn for the worse,” said Dr. Mark Loeb, infectious disease physician and professor at McMaster University. “When you can move forward, you have to do it cautiously. There will be setbacks. It’s going to be like this until there is a vaccine that is proven to be effective and that’s available. We’re going to be in this game for a while.”

Some feel Ontario is ready for whatever hits.

“We have the resource capacity and the knowledge from the first wave to deal with the second wave,” said Dr. Zain Chagla, infectious disease physician at St. Joseph’s Healthcare.

But others say the province is vulnerable, especially in hard-hit areas such as long-term care where the situation has deteriorated over the pandemic, says the Ontario Health Coalition.

“The capacity to provide care is worse than it was entering the first wave,” said executive director Natalie Mehra. “It’s the lack of staffing that has been the biggest barrier.”

Long-term care staffing challenges

The province has limited staff to working at one long-term-care facility during the pandemic to stop the spread of the virus. Having to choose between jobs has “decimated” the workforce in some homes, says the coalition.

“The workforce is so precarious they’ve had to cobble together multiple jobs across multiple facilities,” said Mehra. “That was a lesson the SARS commission highlighted that in the hospitals, workers went from hospital to hospital and that was a danger. But in long-term care it’s much more extreme than in hospitals.”

Compounding the problem is that families ordinarily take on some of the care in seniors’ homes but their visits are restricted due to COVID-19.

“They don’t have enough staff for regular times,” said Mehra. “What has been made very clear is that when you do have COVID-19 outbreaks, there is a need for more staff than the regular times. It has been a complete failure. Those things have been laid bare, but it’s not like they’ve actually been addressed.”

The staffing shortages leave the homes relying on temporary agency workers who are exempt from the order prohibiting employees from working in multiple homes. It raises concern they will inadvertently spread COVID-19 from home to home in the same way workers did in the first wave before the new rule was put in place.

“We learned a lesson that the spread of infection is not necessarily from patient to health-care workers,” said Chagla. “It was also that health-care workers … spread it to other health-care workers. That was a pocket we didn’t anticipate.”

Staff need to be hired immediately to avoid a repeat of the terrible toll the first wave took on Ontario’s most vulnerable seniors, says Grinspun.

“We want increased staffing now so we don’t find ourselves in the predicament that we did last time,” she said. “Because, on top of everything, this time you will have influenza and you will have people who are exhausted.”

She says she “honestly believes” Premier Doug Ford when he says he wants to fix the problems in long-term care, but the clock is ticking down to the second wave and no government has a good track record when it comes to seniors’ homes.

“They were abandoned for the last two decades,” said Grinspun. “Government after government after government.”

Niagara Health president Lynn Guerriero said establishing a better system of managing COVID-19 in nursing homes will also help ensure hospitals don’t get overwhelmed if the next wave of the virus is more severe than the first, as it appears to be in other countries including Australia.

Backlogs in the hospital system

Niagara Health, Hamilton Health Sciences and St. Joseph’s Healthcare are still struggling to catch up with a massive backlog of surgeries and other patient procedures that were cancelled in the first wave of the pandemic. Research published in the Canadian Medical Association Journal on Sept. 1, estimates 148,364 surgeries were postponed provincewide from March 15 to June 13. The Toronto researchers estimate it will take 84 weeks to clear the backlog.

“The best thing we need to do between now and the fall is make sure that we have a plan in place for congregate settings,” said Guerriero. “As a hospital system, we can’t really function if we have to always have the capacity to decant long-term care. So you saw that happening in various places where 10, 20, 50 patients, residents of a long-term-care home, with no other option, would have to go to a hospital.”

In Hamilton’s deadliest COVID-19 outbreak, 63 seniors from the Rosslyn Retirement Residence had to be evacuated to St. Joseph’s Charlton Campus and Hamilton General Hospital — most within a matter of hours on May 15 — when the home had no staff left and was shut down. Hospital workers said they’d never seen so many patients admitted at once in their careers.

In the second wave, such evacuations would be a bigger challenge as hospitals work to clear the backlog of postponed care.

“What that means for the hospital is all of a sudden we have to ramp down our procedures,” said Guerriero. “We don’t want that to happen, so I think that the relationships we’ve built with congregate settings and public health need to be strengthened and kept in place so that we are absolutely ready for whatever happens in the fall.”

Many wonder how Ontario’s normally overcrowded hospitals will juggle influenza, COVID-19 and the backlog.

“We are chronically above 100 per cent (occupancy) just to do what we are supposed to do without being faced with a pandemic at the same time,” said Mertz. “Finding the right balance between opening up as much as we can to provide care to those who have waited a very long time but still making sure we are nimble enough to reduce scheduled care when we see things are ticking up again, will continue to be a challenge throughout this pandemic.”

The question is how to keep beds open — an issue that has increasingly challenged hospitals for decades.

“We do have capacity,” said Chagla. “At the same time, we have a plan on how to create more space relatively quickly. I think it’s just part of the new normal that you have to have some capacity.”

But hospitals usually have more patients than funded beds, especially during flu season, so they have to put people in unconventional spaces such as hallways, family rooms and sunrooms — something that has been coined hallway medicine.

“Every year I’m screaming in the media about not enough beds,” said Grinspun. “Picture this year when you will have influenza plus COVID. Unless we really prepare primary care, nursing homes and home care for October, November and December, we are toast in my opinion. The entire system will crumble not only nursing homes.”

Ontario has to break down the silos in the health-care system and improve co-ordination, said Guerriero.

“I think one of the biggest things that has to change … is better integrating the response between hospital, home and community, and long-term-care and retirement homes,” she said.

The RNAO says what’s missing now is a sense of urgency from the provincial government to get ahead of the second wave.

“I have been asking and asking for the plan for wave two and the answer is always, ‘It’s coming, it’s coming.’ ” she said. “A key message is to move faster, much faster, and with a more serious sense of urgency.”

Mertz is also frustrated by wasted opportunities, particularly when it came to the best way to get kids back in the classroom.

“I think we lost valuable time in terms of testing models back in May and June in areas where there was hardly any COVID,” he said. “We were stuck in a one-size-fits-all approach for the entire province for a very long time.”

Local or partial lockdowns?

He says sticking with a regional approach will be even more important as the second wave hits.

“I don’t think there will be a need to shut down the entire province anymore as a whole, but there might be need for local or partial lockdowns along the way,” said Mertz. “I think the main challenge is identifying clusters early and reacting quickly.”

In the second wave, outbreaks are expected to shift more to stores, restaurants, bars, factories, transit and workplaces as services reopen.

“The bigger area of concern now is the community,” said Chagla. “There’s always a risk with some of these indoor, poorly ventilated activities that we see a big transmission event. I think we just have to be smart, universal mask, make sure people are getting tested. Every individual has to make their own risk assessment on how much they want to engage with society.”

A need for transparency in reporting

The Ontario Health Coalition fears the public won’t even know about the majority of outbreaks in the second wave. While public health departments report outbreaks in congregate living and hospitals, they ordinarily don’t reveal cases at businesses.

“The reporting is actually much worse,” said Mehra. “The names are being shielded from public scrutiny. There is no reason why you can publish the name of a long-term-care home with an outbreak, but not a food production facility. It is in the public interest for transparency.”

It leaves the community counting on the businesses themselves to make COVID-19 outbreaks public.

“Some stores have been reporting publicly, but many others have not,” said Mehra. “This is about protecting business interests and that should not supersede the public interest. There’s no reason to hide it, so it shouldn’t be hidden.”

The lull right now between the waves is the time to find a new normal the community can live with for months or even years, say infectious disease experts.

“We’ve gotten to a point that this is as good as it’s going to get,” said Chagla. “We’re not going to eliminate COVID without something in terms of a treatment or a vaccine.”

Over the summer, the numbers of new cases have been low meaning the community has been as safe as it can be.

“I think people can … go back to some semblance of normalcy as long as they are practicing good hand hygiene, distancing and testing if they have symptoms,” said Chagla.

The focus now needs to be on giving people the tools to make the right decisions, said Mertz.

“I think we need to stop asking the question if doing X or Y is safe,” he said. “We really should say how can I do X or Y as safely as possible. Going back to simple principles like the three Cs: Avoid close spaces; crowded places and close contact.

“I hear about people who are still scared to leave the house,” he adds. “If you are not considering things safe enough now than this will be a major problem for you in the months to come because it will likely not get any safer.”

‘Incredible’ testing capacity

The one piece that is already in place for the second wave is the ability to quickly test for COVID-19.

“The testing capacity is incredible in terms of 20,000 to 30,000 tests provincially (a day),” said Chagla. “I think we learned very quickly that you can’t fight the enemy that you don’t see.”

What Mertz wants to stop in the second wave is the shaming of so-called “COVIDIOTS” which he believes ultimately hampers the ability to stop the spread of the virus.

“I think blaming will not help us moving forward,” he said. “If anything, it will result in people hiding what they really did and then we fail with our contact tracing.”

While Hamiltonians could have the chance to test a vaccine candidate in early 2021, Loeb says having an immunization proven to be effective and that’s available to the public is “still a ways off.”

“There is no guarantee the first horses out of the gate are going to work,” he said. “Even if they do, then the question becomes the availability — which countries are going to get those. The United States is not going to be giving vaccines to Canada before they’ve vaccinated their own country — that’s pretty clear. Canada has to make its own arrangements to secure vaccine.”

Until then, Ontario is left bracing for the next wave — particularly as children go back to school — whether it’s ready or not.

“We’re probably not going to see a surge in a day or two … it’s going to happen over weeks and months that we’ll start to see rises in cases and, hopefully, we can respond to them to keep them relatively low,” said Chagla. “We’re at a point where we can breathe, think about and reflect on where we’ve been and on the next wave.”

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