Fahad Razak, Arthur Slutsky and David Naylor are physicians and professors in the Department of Medicine at the University of Toronto. Drs. Razak and Slutsky are also on the medical staff of Unity Health Toronto.
Consequential policy decisions abound in pandemics. One such decision was required earlier this year as vaccines emerged — highly effective, yet difficult to procure against stiff global competition for a constrained supply. At the time we among many others advocated that Canada should follow the U.K. model. Give initial jabs to as many people as possible by delaying second jabs, vaccinate individuals at greatest risk of bad outcomes first, and maintain public health measures to ensure protection of the unvaccinated or those with compromised immune systems.
Now three months after our April peak, cases rates in Canada have decreased 20-fold and we face a new set of decisions. How can society reopen safely with the dangerous Delta variant as the dominant SARS-CoV-2 strain from coast to coast?
We can again use the U.K. as a crystal ball for policy options, but this time the images are unclear. At the outset of the COVID-19 pandemic the U.K. flirted with a laissez-faire approach designed to create herd immunity through mass spread of infection among lower risk individuals. It has returned to that course in June, albeit alongside an immunization program that has reached a clear majority of the population.
New COVID-19 cases spiked to more than 50,000 on July 17th alone. Nonetheless, England in particular lifted nearly all remaining pandemic restrictions on July 19th. Defending the anointed “Freedom Day” against a firestorm of domestic and international criticism, Prime Minister Boris Johnson warned against deferring the inevitable and asked, rhetorically: “If not now, when?”
The results of this experiment have been mixed. In recent days, case counts have been falling, now sitting at about half the peak level, less than two weeks after “Freedom Day.” Deaths have been rising but are a small fraction of the daily toll during Britain’s giant winter wave — as are hospitalizations. However, hospitalizations for COVID-19 are still rising steadily in England as compared to Scotland, Northern Ireland and Wales — a reminder that “Freedom” has its price.
On that latter point, let us be clear — there are only two ways that immunity can develop to SARS-CoV-2: infection or vaccine. Provinces will decide in the coming months which route becomes the predominant mechanism of exposure for three groups of Canadians: those who are vaccinated but did not mount a full immune response (either because they have only received a single dose so far or have a less robust immune system), children who are too young to be vaccinated (under 12), and unvaccinated adults. These groups currently represent more than 40% of Canada’s population. Given their numbers, we believe uncontrolled viral spread as the path to Canadian immunity poses unpredictable risks for several reasons.
First, the Delta variant now dominant in Canada is much more transmissible and much less responsive to a single vaccine dose. Uncontrolled spread means many thousands of Canadians will become acutely ill with the Delta variant, with the unvaccinated at much greater risk of hospitalization and death. There will be more pressure on healthcare systems struggling to clear massive backlogs, and many lives will be lost. Full vaccination has proven to be remarkably effective in preventing death from Delta.
Second, it’s true that widespread immunization will attenuate the relationship between symptomatic COVID-19 and hospitalizations or deaths. However, the latest estimates from the World Health Organization suggest that as many as 1 in 10 individuals have debilitating symptoms after their infection has cleared. Furthermore, the risk of post-COVID symptoms is still unclear for fully immunized persons with breakthrough infections.
Third, uncontrolled spread is economically disruptive. A “pingdemic” descended on the U.K. in recent weeks, as digital alerts of close exposure to COVID-19 forced hundreds of thousands of citizens into quarantine. Shortages in food and gasoline occurred, and transit disruptions rolled out across the country as supply chains splintered and staffing shortages surged.
These uncertainties indicate that Canadian jurisdictions should take a stepwise approach to dropping public health precautions over the next few weeks. That strategy will give everyone a better sense of how the U.K. is faring. Canadians will also have a front-row seat as Alberta embarks on its own version of the U.K. experiment.
Above all, prudence and patience will give time for all our weapons against COVID-19 to be marshalled before we start moving back indoors. Those weapons are anything but secret. First and foremost, more Canadians must get vaccinated as soon as possible. The next phase of immunization will require a patchwork of strategies like mobile clinics, pop-ups in low-vaccine-uptake neighbourhoods, door to door jab delivery, multi-lingual advertisements and local ambassadors. It means empowering family doctors and community leaders to spearhead further vaccine rollouts. And it means public campaigns to address vaccine misinformation.
Fortunately, Canada has proportionately few hard-core anti-vaxxers compared to many other countries – likely only 1 in 10 Canadians according to a recent Angus Reid poll. If provinces are creative, nimble, and empathetic in their strategies, full immunization of 90% of the eligible population is feasible.
We also need time for the science of vaccines to redefine vaccine eligibility. A raft of trials in children under 12 should yield results this Fall. Booster trials for adults who have been fully vaccinated are underway, and evidence from groups such as the elderly or the immuno-compromised who have already received a third shot will drive evolving policy on that issue.
Blunting COVID-19’s aerosol nature will require a collective effort to ensure buildings have the necessary ventilation and filtration in place by the onset of colder weather. A measured reopening allows an opportunity for that retrofitting to occur. And for heaven’s sake, let us maintain a public indoor mask mandate until we are truly out of this pandemic.
A controlled reopening with a balanced dashboard of outcomes also puts Canadian jurisdictions in a stronger position to suppress future surges through effective test-trace-isolate strategies that protect individuals and minimize economic and social disruptions. Those strategies cannot be effectively implemented in the presence of uncontrolled spread.
Finally, if the focus is primarily on vaccines as the safest path to broad immunity against SARS-CoV-2, there must be broad alignment of policies and incentives in favour of that option. Vaccine certificates are being deployed globally, as are mandatory vaccine requirements for a range of workplaces such as healthcare settings, schools or universities. We encourage both governments and the private sector to implement such a strategy which will mitigate ongoing spread of the virus, encourage vaccinations, and will at the same time help the economy return to normalcy by providing safer indoor spaces.
In short, Canadians know what must be done to ensure that any fourth COVID-19 wave in the fall is manageable and that its toll is minimized. We sincerely hope that the current downward trends in the U.K. continue. But let us not forget that nearly 1.5 million additional COVID-19 cases have already occurred in the U.K. during their current wave—a staggering number. For now, Alberta’s decision to follow suit is hard to comprehend. We urge other jurisdictions to keep moving forward at a more measured pace, using the last weeks of summer to build strong bridges to a post-pandemic Canada.