Michael Warner is the medical director of critical care at Michael Garron Hospital.
It is time for a dramatic shift in how we approach COVID-19. Our testing and tracing systems are under incredible strain, and our hospitals aren’t far behind. Some recently implemented public health restrictions, particularly in Ontario, may be helpful, but they won’t be enough. What is needed is an entire rethink of our public health strategy prioritizing the unique needs of the people who are most vulnerable to contracting COVID-19 in the first place.
On Oct. 9, Ontario Premier Doug Ford announced new public health measures for Toronto, Ottawa and Peel Region targeting indoor activities considered high risk for transmission of COVID-19. Restrictions will be implemented for 28 days but modellers expect case counts, hospitalizations and ICU admissions to increase in the weeks to come. Limiting access to testing by way of narrowing the criteria and implementing an appointment system may help ease the testing backlog, yet demand still exceeds lab-processing capacity.
Prolonged test-result turnaround times delay the initiation of case and contact management, rendering investigations more complicated and less effective. In Toronto, contact tracing teams are so overwhelmed by the volume and complexity of cases that investigations are restricted to cases originating in congregate settings.
Limitations to testing and contact tracing are unlikely to improve in the foreseeable future. The government will not be able to rely on rapid testing as a way to overcome the problems with the current system as it will be many months before rapid tests are widely available.
Given limited laboratory and public health resources and the anticipated spread of COVID-19, the Ford government can improve our collective situation by revising its strategy and redeploying resources to protect and support members of the at-risk communities most likely to be infected.
Sociodemographic data reveal that outside of long-term care homes, racialized and marginalized communities have been most affected by COVID-19. Data from Toronto Public Health show that 82 per cent of COVID-19 cases in the city have occurred in non-white individuals. The poor also fare worse, with case rates of 223 per 100,000 for households earning less than $30,000 a year versus 42 per 100,000 for households with annual income greater than $150,000.
As a physician who cared for exclusively poor, racialized and marginalized COVID-19 patients in the ICU during Wave 1, it is clear that the test, trace, isolate and support system needs to be redesigned to prioritize the needs of these individuals.
Online and phone-in appointment-based testing can be difficult to navigate for members of at-risk communities. Individuals may have limited internet access, speak a language other than English or French and have difficulty co-ordinating time off work for a scheduled appointment. For some individuals, the challenges in obtaining a timely test, and subsequent delays in getting a result, may lead them to forgo getting tested altogether, especially if symptoms are mild.
To overcome barriers to accessing a test, some hospitals have deployed pop-up testing centres in at-risk communities. This ad hoc system needs to be expanded and organized into a formal mobile testing program with sites selected based on case location data from Waves 1 and 2.
Bringing testing to those who have higher pretest probability of being positive is a better way to deploy limited resources and should be prioritized well ahead of expanding pharmacy testing for asymptomatic individuals. At-risk communities tend to be urban and high-density, which can exacerbate the spread of COVID-19. During Wave 1, our COVID-19 patients commonly came from the same apartment building, and even the same unit. Swabs from mobile testing units collected in at-risk areas should be triaged for immediate processing. The faster these tests are finalized, the sooner high yield contact tracing, isolation and support activities can be initiated by public health.
In certain jurisdictions, including Toronto, case and contact management teams are overwhelmed. Contact tracing is an arduous task best performed by trained professionals. However, given that some cases are no longer contact traced at all, officials should leverage technology to make it easier for COVID-19-positive individuals to assist.
The COVID Alert app is available in seven provinces and has been downloaded more than four million times. To make this app more accessible, it needs to be available in languages other than English and French. Infected individuals upload their positive test notification into the app. By triaging tests with higher pre-test probability of being positive for immediate processing, positive tests will be identified sooner and subsequently uploaded into the app, improving its efficacy.
In Ontario, COVID-19 test results are available through an online portal. Instead of depending on individuals to repeatedly log-in until their result is available, labs should send a push notification directly to patients' phones when their test is finalized. Positive test results should be delivered along with specific instructions, in the patient’s preferred language, on what they should do next. Public health should also text an information package, which can be forwarded by patients to possible case contacts in their address book.
Once infected individuals and their contacts are identified, the government must make it feasible for them to isolate safely and also provide continuing support to those who end up in hospital.
Developing a comprehensive support system is just as important as having a robust testing and tracing infrastructure. Removing the practical and financial disincentives to getting tested and subsequently complying with quarantine orders makes it more likely that at-risk individuals will get tested in the first place.
On Sept. 12, Toronto’s first voluntary isolation facility opened. The centre allows infected individuals and high-risk case contacts to isolate from those with whom they live. As we now have multiple COVID-19 hot spots in Ontario, additional centres may be needed.
New recovery benefits made available by the federal government, retroactive to Sept. 27, will help ease the financial burden of those unable to work because of COVID-19-related illness, quarantine requirements or caregiving duties. However, most of our COVID-19 inpatients were not only the primary income earner, but also the primary caregiver to children and elderly parents in multigenerational homes. Income support cannot replace the role these individuals played in their family unit. To help families cope with the loss of individuals while they are in hospital, social workers should be hired to perform a needs assessment for families directly affected by COVID-19.
Ontario’s testing system and public health resources will be over capacity for the foreseeable future. The Ford government should take this opportunity to leverage the data and lessons from Wave 1 to refocus its Wave 2 COVID-19 strategy, optimizing the test, trace, isolate and support system for those communities most at risk for infection.
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