A look back at how the novel coronavirus began its spread across the nation and how our healthcare leaders responded

April 8, 2020

By Tristan Bronca

January: Patient zero

The first Canadian case of the novel coronavirus was reported by Health Canada on Jan. 25, 2020, in a Toronto man who had recently travelled to Wuhan, China. The day of his Jan. 22 flight from Beijing, major Canadian airports in Montreal, Toronto and Vancouver had introduced new screening measures for passengers returning from China with flu-like symptoms. The man didn’t have any symptoms when he arrived, but the next day, he became so sick that he required a trip to the hospital.

As is expected to happen with new viruses to which the entirety of a population is immunologically naive, the full force of public health kicked into gear. Paramedics in protective gear brought him to Sunnybrook Hospital where he was isolated in a negative pressure room. Toronto public health announced that they were working “flat out” tracing contacts who were sitting near him on the flight. After all of this, it appears the only person that Canada’s patient zero passed the virus along to was his wife, who came down with milder symptoms and isolated at home. Both would go on to make full recoveries.

At the time China had reported 2,744 cases of the novel coronavirus and 81 deaths, and the very next day would lock down Wuhan what was, at that time, an unprecedented quarantine—public health measures that would reveal much about the virus and its spread.

“It’s possible that these kinds of draconian public health measures could tip the reproductive rate of the virus below zero and stop it,” Dr. Allison McGeer, a veteran infectious disease specialist in Toronto told the Medical Post at the end of January. “If this outbreak had started in a country that wouldn’t do something like this, we would all be saying, ‘maybe if we just did a little bit more, it’ll be OK.’” Experts were concerned about countries with less robust public health systems, but for countries like Canada, there seemed to be little trouble handling a few cases around the edges of the outbreak if China could contain it.

“If (China) fails to control it, they’ll demonstrate that it cannot be controlled,” said Dr. McGeer. “If these public health measures are not enough, then none of the rest of us will be able to do it either.”

February: Travel-related cases

As the New York Times would later report, what wasn’t clear at that point was that by the end of January, travellers from Wuhan had already seeded outbreaks in more than 30 cities in 26 other countries. Some, such as South Korea, Singapore and Taiwan appeared to handle the outbreaks well, by drastically scaling up testing and travel screening, while others like Iran and Italy, fumbled their public health response in dramatic fashion.

But outbreaks in Iran and Italy didn’t take off until late February, and so naturally Canada’s travel-related precautions remained fixed on China. Dr. Theresa Tam, the country’s top public health official, advised anyone who had come from Hubei province to limit contact with others for at least 14 days after arriving in Canada. On Feb. 6, 14 days after the quarantines began—the maximum incubation period for the virus—Dr. David Williams, Ontario’s public health chief, said that they would begin testing patients with symptoms who had come from other Chinese cities outside the quarantined area. These travel-related control measures focused mostly on educating travellers from cities about the risks of the disease and what to do if they fell ill. People who showed symptoms were asked to self-isolate and inform public health. For the broader population, public health began to stress the importance of basic hygienic practices (hand washing, not touching one’s face, etc.) to stem any spread that may have gone undetected.

It wasn’t until Feb. 20, that Canada reported its first case related to travel outside mainland China—a traveller from Iran. By Feb. 26, Canada had 12 confirmed cases. The first nine related to travel from China and the last three related to travel from Iran. At that point, Iran had reported about 139 confirmed cases, a strikingly low—and almost certainly underreported—figure considering the country was already exporting cases. As Reuters reported, the only reason these travellers were even tested was because a few doctors were suspicious and had both the discretion and swab supply to test more widely than they would eventually be able to. A few days later, Italy’s outbreak began.

On Feb. 26, Dr. Tam told CTV that “as more countries are infected, the less effective and feasible it is to close our borders.” Dr. Tam and others had also resisted calls for more aggressive screening at borders such as temperature-taking. Both the World Health Organization (WHO) and Canadian research in which Dr. Tam was personally involved had suggested such measures weren’t effective. During SARS in 2003, Canada had screened 6.3 million people in airports and concluded that the predictive value of temperature taking was effectively zero.

By the end of February, Canadian leaders continued to resist calls to shut down borders as some other countries had done. As federal health minister Patty Hajdu would point out March 11, Italy closed their borders to China well before it experienced one of the worst outbreaks outside of China. The U.S. did the same with Europe as outbreaks in Italy and Spain began to spiral out of control in early March. And yet, as of this writing, the U.S. has more than double the number of confirmed cases of any other country in the world.

Still, as infectious disease expert Dr. Isaac Bogoch told the Medical Post March 6, travel bans aren’t entirely ineffective, even if they are largely ineffective as the sole or primary protective measure. What they do is buy time, ideally for countries to scale up other public health measures such as testing. As he put it: “It just slows down the inevitable.”

March: Local transmission and testing

In the first 10 days of March, Canadian cases began to climb as the country began importing cases from places that, at that point, were not known hotspots—India, the U.K. and the U.S. Compounding the issue was the now growing body of scientific findings suggesting that the virus could be transmitted by asymptomatic people. At the end of March, Iceland, which has a population of 360,000, began wide-scale testing including those without symptoms and those who were not in quarantine. After testing about 18,000 people—about 5% of its population—about 50% of the positive tests were asymptomatic.

Health Canada did not officially report that local transmission had become the “primary source” of cases in the country until March 24 (at which point there were a total of 2,792 confirmed cases). But there is evidence to suggest there was local transmission going on much earlier—possibly as early as March 1. Most notably, a Sudbury man tested positive for the virus which he was believed to have contracted at a mining conference in Toronto. The event, which took place March 2 to 5 attracted about 25,000 attendees from around the world. It’s unclear how many Canadians from that conference eventually tested positive, but a few days later, on March 5, Canada reported what was then its first confirmed local transmission at a dental conference in Vancouver. At least 20 people who attended the conference contracted the virus, one of whom died.

Testing criteria across the country remained focused on travel-related cases well into March. Massive designated assessment centres opened in mid-March to handle the coming deluge of patients with symptoms, and several provinces and cities launched self-assessment tools to help triage patients so they would avoid waits and being turned away for failing to meet the testing criteria. Those tools instructed anyone with any symptoms to stay home and stay away from other people. Meanwhile provinces were attempting to scale up capacity to meet what all agreed was a necessary demand. Ontario is still, as of this writing, aiming to process 5,000 tests per day, and Alberta’s per capita testing rates as of mid-March were already among the highest in the world. As of March 28, all of the provinces and territories had performed well over 100,000 tests to detect around 7,300 cases.

Still, while doctors technically had the discretion to test who they felt they needed to, a shortage of supply meant they would have to make choices. Those choices usually meant that local transmission was less likely to be caught. It was a tipping point that, as Globe and Mail columnist André Picard noted, experts knew was coming: the shift from containment to mitigation. On March 17, Dr. Tam announced that, faced with practical limitations, provinces should “prioritize Canada’s most vulnerable citizens, including elderly residents of long-term care facilities and those who have travelled to COVID-19 hot zones.”

But those hot zones were also changing. Canada’s attitude on travel took a turn around March 13. Two days after the World Health Organization declared a pandemic, Health Canada advised travellers to avoid all non-essential travel “until further notice,” and three days later, on March 16, instructed all travellers entering Canada from anywhere else in the world to go into quarantine for 14 days. Two days later, on March 18, Canada further tightened those measures announcing a ban on all foreign nationals entering Canada and that all returning Canadians and international arrivals would be funneled through airports in Toronto, Calgary, Vancouver or Montreal. Ottawa also reached an agreement with the U.S. to suspend all non-essential travel across the border. The agreement applied mostly to tourists and shoppers, and would not affect trade or supply chains, nor any essential services.

Around this time, Canada also clarified messaging on travel (earlier in the month, returning passengers including those from known hotspots such as Italy, reported that they were not given clear instructions to quarantine or isolate). Passengers showing symptoms of COVID-19 would also be prohibited from boarding flights into the country. On March 25, the government announced a further step up. It would be using the provisions of the quarantine act to level fines and penalties on any returning travellers who broke the mandatory 14-day quarantine.

Of the dramatic change in stance on travel, Trudeau said: “We have seen over time, various countries take very stiff border measures that proved ineffective. . . . We’ve now come to the point where the best advice from public health officials is that additional border measures on top of the social distancing measures that we are encouraging domestically is the right combination to move forward now.”

The present: A state of emergency

While the testing (case finding, targeted isolation) and travel advisories were the first lines of the proverbial defense against the virus in Canada’s public health arsenal, the situation changed rapidly March 12. The NBA postponed its season indefinitely, and other major sports leagues did the same. Universities and schools across the country shut down, and within days restaurants, eateries and coffee shops all pulled up their seating. Transit has largely emptied, people who were able began working from home, and essential retailers and grocery stores introduced precautionary measures to keep people at least two metres from one another.

Before the beginning of March, hardly any Canadian had ever heard of social distancing, a phrase that directs anyone in any public place to stay out of cough/sneeze range of everyone else at all times. It is now, by necessity, a daily practice and, according to experts, the most important one in the fight to stop this contagion.

Between March 12 (Quebec) and March 22 (Nova Scotia) every Canadian province and territory had declared a state of emergency, with gradually tightening restrictions. On March 29, Ontario lowered the number of people who could gather in one place to five people, and imposed penalties for those who flouted the orders. At the end of March, the maximums on gatherings of people range from 50 (B.C.) to zero (Quebec, in any places outside homes, workplaces or retailers).

Still, as of this writing, the number of daily new reported cases continues to rise in Canada. The effects of these local public health measures could take several more weeks to become evident. As Picard wrote in his March 11 column calling for the complete shutdown of Canadian life: “There is a saying in infectious disease circles that once you know where a virus is, it has already moved on. With coronavirus in the community—in B.C., Ontario and in alarming numbers in that big country just to the south of us—we can’t stop the spread anymore. But we can slow it.”

The rate of growth in certain parts of Canada suggests that we have done that, to some extent. On March 27, B.C.’s top public health official, Dr. Bonnie Henry, said that provincial modelling had suggested social distancing had slowed the spread of the disease. According to their figures it had cut the number of new cases by as much as half of what they would be otherwise. The news came as part of a report which determined B.C.’s 17 major hospitals were “reasonably” well-prepared to handle the overflow of cases. The key caveat was the population would have to continue to follow the advice of public health and continue social distancing and other measures for at least several more weeks.

Dr. Henry described it as “a glimmer of hope.” MP

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