As the provinces lay out plans to reopen their economies by relaxing the measures imposed to stifle the spread of COVID-19, they are setting up a critical test for what was once a small branch of public health – communicable disease control.
A recruitment drive for health officials with epidemiology skills has tapped a wide range of staff and trainees to bolster the ranks. Medical students, resident doctors, nursing students, health inspectors for restaurants, tobacco enforcement officers, environmental health officers and nurses who normally deliver school immunizations have been reassigned to the investigative work of tracking down people who may have been in contact with someone who has tested positive for COVID-19.
British Columbia has had one of the lowest rates of COVID-19 testing in the country, but is now expanding both testing and contact tracing, in a bid to quickly catch and stop the spread of the coronavirus that causes the disease as physical distancing measures are eased. Details are expected to be announced this week about how those emergency measures will be lifted, and the province’s health authorities have been preparing for new outbreaks that might result.
Alberta has had one of the highest per-capita COVID-19 testing rates in the country, but in recent weeks Alberta Health Services realized its contact tracing methods needed to be adjusted when it was chasing down connections related to meat-packing plants in High River and Brooks, which are largely staffed by immigrants and temporary foreign workers.
B.C. is now conducting about 2,500 COVID-19 tests daily, which led to dozens of confirmed cases every day. Every single confirmed case must be investigated, an often-arduous process with public-health officials working against the clock to retrace the infected patient’s whereabouts, and then find anyone who may have been exposed to the virus to ensure that they don’t, in turn, spread COVID-19 to their contacts. Each case can have anywhere from a few in-home contacts to dozens. Public-health alerts have been issued when tracking individuals in a public setting has proved impossible.
A Vancouver poultry plant outbreak, which has led to the closing of two facilities and more than 90 COVID-19-positive cases, began with a single confirmed case.
A COVID-19-positive case was reported to the Vancouver Coastal Health authority on April 19, a Sunday. A doctor on the contact tracing team began the investigation with an interview with the patient, which revealed a worrying detail – the individual had been at work in close quarters at the United Poultry chicken processing plant. When the plant opened on the following Monday, one of the newly formed pods of communicable disease experts from the health authority arrived, and the team quickly discovered the patient hadn’t been the only one going to work while sick.
“They discovered as they walked into the plant that there were obviously people with illness working that day, so they just screened everybody in the plant,” Patricia Daly, Chief Medical Health Officer for Vancouver Coastal Health, said in an interview. “There were a lot of contacts, because they had been working in a setting where they were actually very close contact with one another, and they really didn’t have an appropriate plan to try and prevent exposing one another.”
The outbreak, which quickly spread to a related chicken plant, has been one of the province’s largest single points of COVID-19 infections to date, and underscores the need for caution as B.C. lifts physical distancing requirements.
“We know that we’re going to be judicious about reopening things, because the fires have not disappeared,” Dr. Daly said.
British Columbia has, since mid-April, opened up testing to anyone with COVID-19 symptoms, but the number of tests is still well below capacity.
Each of the province’s five regional health authorities is responsible for its own team, and services have expanded in those regions where COVID-19 cases have been highest. Fraser Health has bumped up its contact tracing team to a force of more than 200 people from 14. The teams are divided into specialized hubs to deal with different sectors, such as long-term care homes or factories.
Vancouver Coastal had seven nurses tasked to contact tracing before the pandemic – now it has 12 teams or pods, each with six investigators. The pods are set up so that they can be divided and bolstered with new staff as needed. Vancouver Island Health has doubled its team, and Interior Health now has trained more than 100 public-health nurses to do this work. Northern Health has had few cases but has tapped other health officers, such as its tobacco enforcement officers, to help.
In Alberta, the challenges in contact tracing were brought to light in its response to the outbreak at Cargill Ltd.'s Alberta slaughterhouse, where more than 900 employees have tested positive.
“I don’t think that we did have that detailed understanding of that conflict between the health advice we were providing to people” and how the advice was interpreted or the logistical difficulties some members of immigrant communities face when trying to follow the advice, according to Brent Friesen, a Medical Officer of Health in the Calgary zone.
Alberta Health Services turned to experts in refugee and immigrant health, leaning heavily on the Mosaic Primary Care Network, to reach out to all affected Cargill employees. Annalee Coakley is the medical director of the Calgary Refugee Health Program and was pulled into the effort about two weeks ago, in part to strengthen AHS engagement with the community.
“It is not enough to provide public-health guidance without providing people with the support to actually adhere to that guidance,” she said. “If it is: ‘Please don’t carpool.’ Well, you actually have to provide people with an alternative.”
Dr. Coakley and her colleagues are working with organizations that can help address these problems. For example, they help connect people with agencies that can help newcomers access income support from governments, making them less inclined to show up for work when they should be isolating, or find grocery delivery services so they can stay indoors.
Communicating directly to vulnerable groups in their mother tongue is key, she said. Dr. Coakley and her peers have more experience using language interpreters when practising medicine and reading nuances in patients’ responses. Health care professionals who first contacted sick Cargill employees may have not picked up on language gaps, even when COVID-19 patients responded in English or through interpreters.
Public-health officials are better equipped now to track COVID-19, but they remain worried what the repeal of restrictions will bring.
“It is my big caution, as we look at relaxing some of those measures in society, that people still need to be very aware that this virus is easily transmissible,” said Dee Hoyano, Medical Health Officer at Vancouver Island Health.
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