Health Committee on May 20th, 2020

[Dr. David Fisman]

I think the idea is that economically it holds a country back. Even if we have 40% of our workforce able to work from home, for the parents, it's often difficult to get their jobs done if they're minding children in parallel.

However, yes, it's an issue. Countries like Korea have kept their schools closed. Hong Kong continues to have its schools closed. I think they're just starting to reopen, because they have approximately zero cases at this point.

I think places with good public health leadership have done it very cautiously. Kids are the transmitters of infectious disease for many respiratory diseases, even if they themselves tend not to be sick from them.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Dr. Khan, I will go quickly to you.

I know you did a commendable job. An article in U of T News said that BlueDot was among the first to warn the world of a potentially dangerous new illness, COVID-19. You rang the alarm on December 31, 2019, before both the U.S. Centers for Disease Control and Prevention or the World Health Organization. You also predicted the next 11 cities that the novel coronavirus would hit.

You're quoted as saying, “We didn’t necessarily know it would be of this size.... But what we did know is that it had the ingredients.”

Approximately when were you aware that COVID-19, or the novel coronavirus, had the potential for serious, significant, widespread transmission?

[Dr. Kamran Khan]

I think the point—and this is sort of a gradient—was literally December 31. First seeing that information certainly caused some alarm. Around the middle of January—and I'd have to double-check the exact date—was when the first case showed up in Bangkok.

I'll give you a bit of a sense of the increasing concern.

When we learned that this was a novel coronavirus, I believe somewhere around January 8 or so, there was concern for all the reasons I mentioned earlier, MERS and SARS, and comparing those: no vaccine, no effective antivirals, no underlying immunity and we were in the middle of flu season.

What we had been learning up until that point is that the number of cases being reported in China were in the dozens. When the case showed up in Bangkok, which was the top place we had concerns about because of the movement of travellers from Wuhan out into the region, in a city of 11 million.... The math doesn't work if you have a case show up in another city and knowing the volume of travellers who were leaving. That was the moment for me and our team, when we were really quite concerned.

Again, we didn't have all the answers, but we were quite concerned that this was a novel coronavirus. The outbreak was much larger than it appeared to be. This inevitably told us this was not just a spillover event. This was not just the people who were at the market who became infected. If there were hundreds or thousands of cases, this had to be something that was more efficiently being spread from person to person.

It was roughly around the middle of January that we had serious concerns about how this might unfold.

[The Chair, Liberal, Ron McKinnon]

Thank you.

That brings round two to a close. We start round three with Mr. Webber.

Mr. Webber, go ahead, please, for five minutes.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you, Mr. Chair, and thank you to all our presenters, whose opening remarks were very interesting indeed.

My first question is for you, Dr. Attaran. Thank you for sharing with the committee your paper on the pandemic data sharing. In this paper, you mentioned the SARS issue back in 2003 and how the World Health Organization demanded epidemiological data from Canada about the scope of the epidemic back then, particularly in Toronto. The problem was that Canada had no way to fulfill the World Health Organization's demand because of the jurisdictional fight that you described today with regard to data sharing.

Because of that, Health Canada was in no position to answer the World Health Organization's questions, so they grew afraid of Canada. They thought that Canada was concealing this epidemiological data, which then resulted in the World Health Organization recommending against travel to Canada, making Canada one of only two countries—that and China—that they sanctioned back then.

Sadly, I see this occurring again. Dr. Attaran, do you see this occurring? What will the implications be of being sanctioned once again?

[Prof. Amir Attaran]

Mr. Webber, you summarized that exactly right. Back in SARS, there were two countries in the world that got slammed with a WHO travel advisory, and we were one. China, not exactly having been honest, shall we say, was the other. Now, we weren't trying to deceive, the way China was. We were just unable to be honest. We were unable to get the data from Ontario to Ottawa and then onward to Geneva, where the WHO is.

Nothing has changed. That is a risk that could repeat itself. Yesterday, I believe it was Dr. Kitchen who asked about the multilateral information sharing agreement, which is an accord between the provinces and the federal government to share data. It is so secretive and ineffectual that to this day we don't know which provinces have signed that agreement and which have not. Can you believe it?

As for the Public Health Agency, I've asked them that question directly. Which provinces have signed the information sharing agreement and which haven't? They won't answer the question. Parts of that agreement actually stand in the way of data analysis, the sort that Dr. Fisman does. Under that agreement, provinces have to give their permission before analyses using their data can be published, which means that they have the ability to suppress analyses that can save lives. It's terrible.

[Len Webber, Conservative, Calgary Confederation, AB]

It's unbelievable, Dr. Attaran, it really is. Thank you for sharing your testimony today.

Dr. Fisman, again, thank you as well, and thank you for your work, your commitment and your sacrifices, too, along with those of all health care workers in Canada. Thanks to all of them.

You've talked about some of the best practices around the country. It's in Nova Scotia, I think, that you indicated they hunt the virus, and you also talked about how in Saskatchewan they deal swiftly with and contain areas of outbreak.

Then you talked about Alberta and how they've scaled up their testing and are the most potent and aggressive testing province in the country. I'm just at odds here. I don't understand. How come Alberta can do it but the rest of Canada cannot? Where are they getting their testing material? What's their secret in Alberta?

[Dr. David Fisman]

Do you know what? I'm not sure to what extent I can talk about private conversations in this public forum but, as I speak to colleagues across the country, what is clear to me is that the places that got the job done were aware of their deficiencies as laboratory systems and worked with commercial partners to automate processes in their labs. It's one thing to be testing 100 specimens a day. It's another to be testing 10,000 a day.

I think that the laboratories that are able to have high throughput here, and—Mr. Ciciretto is probably the better one to answer this question—we do have folks in the country who know this stuff. From the time the specimen arrives until the report goes out to the public health unit, not by fax but electronically, operations can be tremendously streamlined so you don't get the bottlenecks that we've had in Ontario.

I think a lot of the problems got blamed on the supply chain but clearly, as the supply chain has cleared up, it's still a rocky ride. In Ontario there have been a lot of politics as well. I think you see that. You've had access to some testing data via the modelling process. You see that there's still this hugging going on where, even as testing is supposed to get dispersed out to hospital labs and private labs, it's still getting hugged by the public health laboratory system.

I think, in a time of national crisis, it's time to check your ego and work with whoever you can work with. Essentially, the folks in Newfoundland.... It was a remarkable experience to interact with them. Perhaps this is a size thing, but it seemed a lot to me like an ego thing. They have a provincial working group that has some former politicians, some leaders from health, leaders from business and a couple of academics, and they're all at the table and they're all exchanging ideas. It reminds me of the children's story, Stone Soup, where everyone brings something and puts something in. At the end of that, they all have a good soup to enjoy together.

That's how they do it in Newfoundland. It was a revelation to me, as someone coming from Ontario who's used to being asked for information that then goes off into a dark place and you're never really sure who's seen it, used it or responded to it. It's just a very different way of doing business, and I think it's served them well. They got the idea of hunting the virus from Iceland. They looked over to the east and thought, “Well, you know we've got Canada over to the west and we've got this other country over to the east, and the country to the east is doing a bang-up job. Let's talk to them.”

I think being humble and looking for folks who are doing this better than you, and learning from them, is part of the magic.

[Len Webber, Conservative, Calgary Confederation, AB]

Absolutely, it is.

[The Chair, Liberal, Ron McKinnon]

Thank you.

Mr. Van Bynen, go ahead, please. You have five minutes.

[Tony Van Bynen, Liberal, Newmarket—Aurora, ON]

Thank you, Mr. Chair. Thank you, Dr. Fisman, for joining our committee today. It's so refreshing to hear such a wide variety of perspectives, and that certainly helps us to develop a good understanding of the situation that we're trying to find some solutions for.

It's my understanding that you co-authored a study that examined the impact of enhanced contact tracing and restrictive physical distancing measures in comparison to a combination of enhanced contact tracing and less restrictive distancing measures.

Could you please share with the committee the findings of your study and what the implications may be?

[Dr. David Fisman]

I think what you're referring to was our paper in the Canadian Medical Association Journal, CMAJ, in March. Our model looks a lot like most other models by competent modelling groups. It looks like the publication by a guy named Steve Kissler, in Science, that happened about a month after.

What we projected was that reducing transmission through a variety of means can knock down the reproduction number of the disease and prevent intensive care units from overflowing. Something we learned.... We didn't really anticipate that a lot of deaths in Ontario would come in the long-term care facilities. We knew that long-term care facilities were vulnerable, but we assumed, as we were doing our modelling, that people would try to protect them, which turned out not to be the case.

What we've found is that various combinations of case identification with contact tracing or straight physical distancing are sufficient to knock the reproduction number down enough that ICUs don't overflow. This has been the case in Canada, which is wonderful.

Moving forward, we now have a second iteration of that model in press, in a journal called Annals of Internal Medicine. Thanks to the provincial modelling table, we've been able to calibrate the model. That means we've fit the model to real data. We couldn't do that beforehand because we didn't have an epidemic to fit it to. We can fit it to ICU occupancy in Ontario and can fit it to hospital deaths. The long-term care stuff is very challenging to try to fit into any sort of model. What we see is that, basically, the lower disease activity goes and the slower we reopen, the longer it will be before we have a resurgence.

In our paper in March, in the Canadian Medical Association Journal, my colleague, Dr. Ashleigh Tuite, who I've referenced previously and is a brilliant modeller, came up with the idea of dynamic social distancing, which depends on really good public health surveillance, so that you know when your hospital is starting to fill up again and when you have to strengthen distancing measures. I really think the group at Harvard, who we're friends with, may have copied that from us. That came out in the Science paper as well a couple of weeks later. It's this idea—and journalists refer to it as surfing the wave—that we're likely to go up and down and up and down with this disease for a while until we have a vaccine, which may come sooner than I ever would have imagined.

[Tony Van Bynen, Liberal, Newmarket—Aurora, ON]

Thank you.

Yesterday I asked Dr. Tam about the provinces and territories and their plans to reopen their economies, as well as people starting to leave their homes as the weather gets nicer. As a follow-up, with the information obtained from your study in mind, what are your thoughts on how this can be implemented safely?

[Dr. David Fisman]

This is not our work. There's a marvellous mathematician at Waterloo by the name of Chris Bauch who has a paper looking at regional reopening in Ontario as opposed to blanket policies, with the outcome of interest being how we can minimize the amount of time in lockdown.

I think some organic reopening is happening anyway as the weather gets better, and that's all right. This doesn't seem to be an infectious disease that spreads particularly well in parks or as people are out enjoying themselves, as long as they're maintaining a bit of distance. This disease really continues to show that it likes big crowds and indoor places. I think our most recent superspreader event here in Ontario was among greenhouse workers in Chatham, which fits the description to a T: 50 people were infected working in a greenhouse. When folks are in small groups and there's a low upper bound on the number of people they're working with—we call that “work bubbles”—or when folks are enjoying themselves outside to stay fit, going to parks or enjoying the outside with their kids, that generates minimal risk for us.

What we do need is good, strong surveillance systems—and this circles back to our initial conversation about testing—that let us know when we're getting into danger again, as we were in March. I do think we're going to struggle in the fall. Again, there's a lot of hindsight at this point. This thing emerged in January, but we didn't really get serious about it until March, and I think we're going through that again. Anyone who looks at disease dynamics for a living can tell you that we're in a lull now but the disease is probably going to be coming back in September or October. We have some golden time now to get prepared for a likely resurgence in the fall. I think we need to build those surveillance systems and get much better at this by the time we get to the fall, because we're going to have to be more nimble then. There's much we can do, and there's much we can do safely if we avoid large gatherings.

The bubble idea—and a lot of corporations have already instituted this— is simply that if you divide people up into relatively small teams, they don't work simultaneously in the office and there's a deep clean between when teams are in the office, you have an upper bound on how many people are going to get infected if someone comes into the bubble with infection.

I think there's a lot of ingenuity and a lot of wiggle room in reopening the economy safely, as long as we have the surveillance systems that allow us to see when we're getting back into trouble.

[The Chair, Liberal, Ron McKinnon]

Thank you.

Ms. Jansen, please go ahead. You have five minutes.

[Tamara Jansen, Conservative, Cloverdale—Langley City, BC]

Dr. Khan, I'm curious about your thoughts, as a infectious disease specialist, on the current deal that Health Canada has made with China on developing a COVID-19 vaccine.

The announcement mentioned that the National Research Council is working with CanSino Biologics to advance a vaccine, which is being developed jointly with the People's Liberation Army. Apparently Health Canada has even approved the first human clinical trial that will be run at Dalhousie University in spite of the fact that CanSino has not published any data from its first trial phase for any sort of public scrutiny.

This really shocked me. Vaccine development cycles are normally 10 to 15 years, and the shortest ever was four years. Our Five Eyes intelligence alliance has raised concerns regarding China's transparency regarding this particular pandemic. They even denied, initially, human-to-human contact. And some whistle-blowers have disappeared.

If we want Canadians to buy into a COVID-19 vaccine, wouldn't it make more sense to be working with a more trustworthy partner on this sort of thing? Does it strike you as being dangerous?

[Dr. Kamran Khan]

Thank you for the question. I'm going to try to see if I can tackle it.

With respect to vaccine development and partnerships, I would say that I'm not fully aware of all the details of how Canada is looking at vaccine development, perhaps, with the Government of China or with scientific groups in China.

I think all of the points that you've raised are very important. Clearly, there is a race to get to a vaccine as quickly as possible, not only from a preventative standpoint but also to develop therapeutics.

I think I'm probably not well equipped to speak to the broader ethical issues here. I'm just less informed about the specifics of this particular circumstance.

But clearly, the points that you're raising around transparency are critical in any scientific endeavour. I think that is a critical issue.

I'm not sure if, perhaps, Vito or others want to chime in on that.

[Tamara Jansen, Conservative, Cloverdale—Langley City, BC]

My time is limited. I have another question, but not specifically for you.

Going back to Professor Attaran, you mentioned that we could ask you questions about yesterday's meeting.

I asked Dr. Tam about her flip-flop on the use of masks. Up until early April, Dr. Tam stated that an asymptomatic person shouldn't wear a mask. It didn't work. It might even be harmful. Then on April 6, she changed her mind and said that a mask was good for additional protection.

Her response to my question on why her message changed was that, apparently, new evidence had come to light.

As this was a respiratory pathogen, I imagine that out of the abundance of caution, masks would have been helpful right from the beginning.

In your opinion, what sort of new evidence has come to light over the course of this pandemic that would substantively change the way we consider the effectiveness of masks as prophylactics?

[Prof. Amir Attaran]

There's no easy way for me to say this, but Dr. Tam was not being truthful.

In the week or 10 days.... Pardon me, I don't know the exact time span between her statement that masks were not to be recommended to the public and then changing her view to give permissive guidance that masks of a non-medical sort could be used. In that short period of, as I say, about a week or 10 days, there was no new evidence that emerged to justify that change.

There have been additional studies of masks, of course, some of it biophysics, what particle size will penetrate a mask in what conditions. But there was definitely not in that crucial window a game-changing study.

[Tamara Jansen, Conservative, Cloverdale—Langley City, BC]

I have a really quick question. My time is almost out.

You provided a chart in your submission that showed that Australia and, I believe, South Korea had much better pandemic trajectories than Canada did. As with all catastrophic emergencies, there's never just one thing that goes wrong that causes the tragedy, and I assume that's the same when things go right.

What, in your estimation, are the critical things that ensured better outcomes in those countries compared to Canada?

[Prof. Amir Attaran]

Australia, for instance, was very quick at cutting off travel with China. It did so at the same time as President Trump did, but for sounder reasons than Mr. Trump.

It was also incredibly quick at organizing coordination between the states—the provinces, if you will—and the federal government. As I mentioned, they signed an accord on co-operation on March 13. Such an accord doesn't exist in this country yet.

The Australians have, generally speaking, a very strong sense of biosecurity because they are an island continent and they have honed that over years. They're much more attuned to risks coming in from abroad than we have been. The error of not being tougher on travel sooner is one that we will, of course, regret for many years to come.

The Australians also, I feel, were extraordinarily good at their social distancing. Now, precise measures of how aggressive social distancing is are hard to come by. Dr. Fisman would be able to speak to that far better than I could, but even from my inexpert point of view on this, it's clear the Australians did take the social distancing more seriously early on than did Canadians, and that has had an effect.

[The Chair, Liberal, Ron McKinnon]

Thank you.

Ms. Sidhu, go ahead, five minutes.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Chair.

Thank you everyone for coming today.

As you know, I really like all the witnesses. Yesterday Dr. Tam and her team were here.

This committee has really been focusing on supporting Canadians and how we can better help all Canadians.

Today I really want to say thank you to all the witnesses and my first question is to Dr. Khan.

You talked about the rigorous factor and triggering the next wave. Can you explain to the committee how your technology can be used to track second or third waves of COVID-19? What do you see as the biggest risk that's coming?

[Dr. Kamran Khan]

In the technology that we've developed, and I'm going back to that metaphor of smoke detector and fire extinguisher, we've really been focusing much more on developing the early warning systems that could give us a signal that there is a threat coming.

COVID-19 is here now and we're all very well aware of it and we're now sort of more in firefighting mode, grabbing the fire extinguisher to put fires out.

From the standpoint of our technology, the area where we are supporting public health decisions is around an understanding of population movements and how that relates to the transmission of COVID-19 across the country.

With respect to the next set of waves, I have two thoughts. One is clearly the vast majority of the population in Canada remains susceptible, as we've heard. We either could see an uptick in cases later in the fall because of a variety of factors including climate conditions and dynamics of how people are interacting, or we could find ourselves in a similar position to some countries like Australia and New Zealand, where imported cases become the catalyst for another wave.

So we're going to have to be thinking both internally and externally. These are a couple of examples of how our technology is looking internally within the country domestically as well as globally.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you.

My next question is for Mr. Ciciretto. Your company is based in Brampton. Your company recently moved to providing COVID-19 test results online instead of over the phone. How has that increased the efficiency of your testing process?

In Canada today, 1.3 million people have been tested. What do you think? How has online reporting instead of over the phone reporting increased the efficiency of your testing process?