Brooks Fallis is the medical director and division head of critical care at the William Osler Health System.
Canada’s COVID-19 pandemic exit strategy is dependent on a vaccine to establish broad population immunity. While a highly effective vaccine would be ideal, it is naive to hope for a single perfect solution to such a complex problem. To hedge our bets, Canada should attempt maximal suppression of the virus, so success becomes vaccine-assisted, not vaccine-dependent.
The majority of countries are attempting one of three basic COVID-19 strategies: learn to live with it, let it rip while protecting those most at risk, or try to suppress or eliminate it.
In Canada, provinces are mainly accepting significant viral activity to minimize economic disruption – learn to live with it. Investment has been made in public health, but not enough to target suppression. A trade-off is being made between mortality, morbidity and strain on health care resources, and a perceived improvement in short-term economic prospects. This is also the most common approach in Europe. But cases there have skyrocketed recently, leading to lockdowns. Ultimately, this strategy requires a highly effective vaccine to break the cycle of restrictions.
But what if the current crop of vaccines fails to be approved, or do not reduce the severity of illness? What if immunity through exposure or vaccination is not long-lasting and reinfections become common by next year?
We have seen that antibodies can fade or even become undetectable over time. Cases of reinfection have been reported, although the frequency remains to be seen. Studies of other coronaviruses have shown loss of immunity after one to three years.
This does not mean sustainable immunity is impossible. Immune memory is complex and does not rely solely on the continuous presence of antibodies. But equally, there is no certainty that the immune response will be durable.
Even if a vaccine is shown to be safe and effective in phase three trials, it is not a silver bullet. If a vaccine is 70 per cent effective, it would be considered an overwhelming success. Combine 70 per cent effectiveness with 75 per cent vaccine uptake and about half of the population would remain vulnerable. This would not lead us back to our old way of life.
We need an insurance plan: domestic COVID-19 suppression.
A maximal suppression strategy could take two possible approaches. The first is a short but deep lockdown to bring cases close to zero while revitalizing public-health measures to keep the virus suppressed when the lockdown is lifted. The second is targeted restrictions coupled with a methodical dedication to driving down and maintaining the reproduction number below one, thus slowly achieving suppression. The first approach demands more significant short-term sacrifices, but reaches the goal of suppression sooner.
Either approach requires a large-scale investment to restructure and expand our public-health systems. The status quo will never be good enough. Call it “Canada’s New Deal”: Instead of roads and railways, we invest in a world-class public-health system. Strong federal leadership and commitment from all provinces and territories is essential.
This would need to include mandatory and enforced quarantine for all out-of-country travellers, perhaps coupled with a test-based strategy to shorten the quarantine time. We would also need a complete overhaul of our weak test-trace-isolate-support system, including capacity to perform backward contact tracing to find the source of outbreaks and super-spreader events. Another key measure would be developing surveillance strategies using rapid tests and sewage testing to help detect disease early, followed quickly by blanket local testing. Although expensive, the investment would be in medicine, technology and people – leading to job creation and a boost to our troubled economy.
Uncontrolled COVID-19 in the United States certainly makes suppression more challenging, but it should not dissuade Canada from aiming high. We need to learn from other countries that are succeeding in suppression and elimination (New Zealand, Taiwan, South Korea) rather than comparing ourselves to countries continuing to struggle. We have no choice. Our health care capacity is much smaller than much of the European Union and U.S., where well-resourced hospital systems are starting to buckle under the strain of case surges.
Wishfully waiting on a vaccine leads to cycling restrictions, excess death, long-term disability and slow chronic economic hardship for too many people, especially small businesses and hospitality services. Advocating for small business recovery is understandable, but rapid reopening will not save them – only delay their failure.
Canada has invested in multiple vaccine candidates and hopefully one or more will be effective. In the meantime, a national suppression strategy would create jobs, save lives and unify Canadians in the hope of a freer life and a stronger economy – no vaccine required.
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