18 Sept. 2020
It was a tragedy that didn’t have to be. Sadder still, what happened at Vancouver’s Holy Family Hospital was not BC’s first large-scale tragedy of this kind nor does it seem likely to be the last. COVID-19 claimed 20 lives at Lynn Valley Care Centre, 26 at Langley Lodge. 21 died before the outbreak at Holy Family was declared over at the end of August. In total over 160 elderly parents and grandparents of BC have perished under similar circumstances as the virus continues to ravage the facilities which house our most vulnerable citizens. COVID has come to over 70 such facilities. 15 are currently facing outbreaks, including Burnaby’s New Vista Care Home, where 11 residents have already died since the virus entered on August 9. It was brought in by a staff member, just as it was at Langley Lodge and Lynn Valley. The Holy Family tragedy began in the same way.
In fact, according to Patty Daly, the Chief Medical Officer for Vancouver Coastal Health (VCH), “In almost every outbreak…the initial cases were among staff.” Dr. Daly made this statement in reference to 15 long-term care outbreaks that had occurred in VCH when she spoke at a Holy Family Town Hall session on July 16. This is “not surprising,” Daly explained, because the residents did not go out into the community and visitors were not allowed in. Provincial Health Officer Dr. Bonnie Henry has also acknowledged that it is usually staff who bring the virus into our care homes.
Since care home staff are screened daily for symptoms of COVID-19 and not allowed to work if any are detected, it is not surprising that it is almost always asymptomatic workers who bring the virus in. “Staff may come to work not realizing they’re infected,” Dr. Daly observed, also pointing out that we should not “vilify staff of long-term care” because “they may not even recognize they have symptoms of illness.” This is particularly unfortunate for care home residents because a number of scientific studies have shown that carriers of COVID-19 often have extremely high viral loads and are most infectious of all a few days before symptoms of the disease appear.
“If we are successful in identifying a staff member infected with COVID-19 before they have spread it to residents,” said Dr. Daly, “we can stop outbreaks from spreading.” However, if the virus “is transmitted before it is recognized it can be challenging to control the outbreak, and that’s what we’ve seen here at Holy Family.” Since BC does not normally do proactive testing of staff without symptoms, this suggests that it is largely a matter of luck whether an infected staff member will be identified before he or she has spread the virus to care home residents. Neither the staff nor the residents of Holy Family Hospital had such luck. 53 seniors and 35 workers had been infected by the time the outbreak started by an asymptomatic staff member ended.
The Holy Family outbreak might have been stopped before it started had BC adopted a proactive policy of regularly testing care home workers, with or without symptoms. Lives have been saved in Ontario and other jurisdictions, including many American states, that have implemented this practice. In West Virginia, for example, universal testing has identified infected but asymptomatic residents and workers and, according to a recent CDC report, “it has proven essential to limiting COVID-19 transmission in nursing homes and has reduced the impact of the pandemic on this vulnerable population.”
But this kind of testing, intended to stop outbreaks before they start, was not done at Holy Family. In fact, it was not until the third week of the outbreak that BC’s health authorities even made a decision to test all staff. Sifting through the statements of Dr. Daly, it appears that testing did not begin until at least the fourth week of the outbreak. When she spoke at the Town Hall session on July 16, a full five weeks after the outbreak was declared on June 9, that testing had still not been completed. By then, 30 staff members had tested positive and 15 residents were already dead.
Naturally enough, loved ones of Holy Family residents wondered: “Why didn’t all staff undergo mandatory testing at the very start of this outbreak?” Dr. Daly advised them that staff wore personal protective equipment (PPE), washed their hands regularly, and were screened for symptoms twice a day. More to the point, she cited the dangers of false positive and false negative results that might be obtained by testing staff without symptoms.
Not surprisingly given that BC doctors were urged early on in the pandemic to stand united behind Bonnie Henry as the “single source of truth” in public health matters, Dr. Daly’s response echoed almost identical explanations that have been given by BC’s “top doctor,” as she is often described. On April 13, for instance, after an outbreak had started at a Vancouver care home, Dr. Henry was asked: “Shouldn’t all the healthcare workers and residents there now be tested for COVID-19?”
Like Daly, Henry talked about symptom screening and PPE. Then she explained that “the norm is not to test people who do not have symptoms because we know the test doesn’t perform very well.” It was the first time she publicly aired a claim that has since been repeated often by various BC doctors: “The false negative rate can be as high as 30% early on in infection.”
This claim is problematic for several reasons. First of all, as a respected disease ecologist at the University of Santa Cruz, Auston Marm Kilpatrick, has said, “Testing people w/out symptoms sometimes finds infected people but we have no idea if it does so 10% or 90% of the time.” Answering a direct question on Dr. Henry’s claim put to him via Twitter on June 14, Dr. Kilpatrick stated that “no actual data on this have been published,” and that the “30% number is made up.” The BCCDC website suggests that this false negative rate may apply to COVID-19 testing in general—not, as Dr. Henry’s statement indicates, specifically to the testing of people without symptoms.
When Alberta’s Provincial Health Officer Deena Hinshaw was asked about Dr. Henry’s assertion on April 14, she said, “I hadn’t heard that statistic before, and I certainly have not seen any data that would indicate that our false negative rate is as high as 30%.” Since then, like other Canadian provinces and many American states, Alberta has tested thousands of people without symptoms, undeterred by the fear of false negatives.
Even if we accept Dr. Henry’s false negative rate as entirely accurate, however, as a justification for refusing to test proactively, it defies common sense and simple logic—if our goal is to save as many lives as possible. Using the number cited by Dr. Henry, mass testing could enable us to identify 70% or more of the infected but asymptomatic staff who spread the virus in our care homes, starting outbreaks or making them worse. Surely that is far better than identifying none of them. No truly compassionate person could reasonably argue otherwise.
Yet, amazingly, Dr. Henry’s logic on this question has never been challenged by any mainstream BC reporter. Media silence surrounding this issue has, in fact, been a key reason why this flawed testing logic has for so long prevailed at care homes such as Holy Family. Most British Columbians do not know or understand what has been happening in these places in regard to testing. It is not an easy tale to unravel given the confusing and contradictory statements that have been made on this issue by our Provincial Health Officer and other leading health officials.
Consider, for instance, the statements of Dr. Michael Schwandt, who has played a leading role in outbreak control in the Vancouver Coastal Health region. On May 2, Dr. Schwandt posted a series of tweets, headed by one which declared: “If anyone tells you that massive and deadly COVID-19 outbreaks in long-term care are ‘inevitable,’ please tell them otherwise.”
Referring to the dangers of asymptomatic spread, Schwandt said, “watchful waiting is not your friend with the ‘invisivirus.’” He continued: “We are now doing asymptomatic tests of entire floors/buildings/units, and the entire staff of a [long-term care facility] when transmission is suspected. This has routinely identified cases who otherwise would have gone undetected.”
According to Dr. Schwandt, then, not only has mass testing of asymptomatic staff been done in BC care homes; it has also “routinely” proven to be effective and valuable.
Unfortunately, this knowledge was not applied at Holy Family until it was too late for residents who had already been fatally infected. In fact, Dr. Daly’s comments at the Town Hall session indicate that it has very rarely been applied in BC care homes. The Holy Family outbreak, she said on July 16, was the 15th long-term care outbreak in Vancouver Coastal Health Region, and the only one where authorities had decided to test all staff regardless of symptoms. And since the decision to do this testing was not made until the third week of the outbreak, it clearly was not a standard or mandatory procedure. Even today, mass testing of staff is not automatically done when care home outbreaks begin.
Yet Dr. Henry has on more than one occasion made statements that strongly suggest otherwise. The one she made on July 27 is particularly troublesome. Asked a general question about the low level of testing in BC, she declared that “we also do testing of people who are asymptomatic in specific situations.” In long-term care homes, she said, “we test all of the residents, all of the staff, whether they have symptoms or not.”
As it turned out, the devil was in the details of this statement. Initially, however, many people who have loved ones in long-term care undoubtedly breathed a sigh of relief on hearing this. As one of those people who has followed the issue closely and was well aware of what had just happened at Holy Family, I wondered whether BC’s testing policy had very recently changed. But the outbreak protocol posted on the BCCDC site had not—and has not—changed. It still calls only for the testing of residents, not staff, after an outbreak begins.
On Aug. 13 Dr. Henry compounded the confusion on this issue by declaring that “we test everybody in a care home if there’s a case there.” Given the context of her statement, one must assume that by “everybody” she meant all of the residents, not all of the staff. That is, in fact, what is happening still, and the point should have been more clearly stated. Reports on new care home outbreaks since then list the same protocols— “enhanced control measures” such as extra cleaning, restrictions on visitor and staff movements, and twice-daily screening of staff —that have failed to end the continuing carnage in BC care homes.
Finally, on August 24, Dr. Henry explained the situation, past and present, more clearly than ever before. This came when a CBC reporter asked a very specific question: “Are [long-term care] staff tested regularly for COVID, and if not, why?”
“No,” she said. “What we do, and what we have done from the very beginning, is about screening.”
Screening should not be confused with testing, as Dr. Henry made clear when she said: “What we are doing is focusing on the daily symptom screening.”
Dr. Henry went on to explain that “we have protocols” in the event of an outbreak. If a single case is identified in a long-term care facility, she said, “then we have wide screening of everybody in that facility.” This response is puzzling because screening for symptoms has been a mandatory daily procedure in all BC care homes since the early days of the pandemic. Presumably, she was referring to the fact that staff are screened twice daily during outbreaks.
Perhaps the most disturbing part of Dr. Henry’s answer was the reason she gave for not regularly testing staff without symptoms. Such testing produces “very low yield,” she explained, and “that is, in my mind, not a great use of resources.” Tests of this kind, she suggested, “aren’t going to help us.” The loved ones of the 21 seniors who died at Holy Family would surely beg to differ.
While the virus spread silently through the Holy Family facility for at least three weeks in June, BC used about 20% of its testing capacity. About 6,000 tests were left unused every day during that period. Why have these resources been deemed more valuable than the lives of our elderly parents and grandparents?
Until recently BC had habitually used 20-30% of its testing capacity, which remains meager compared to other large Canadian provinces. Despite improvements in recent weeks, BC’s per capita testing rate remains almost 60% lower than the Canadian average. Moreover, as we have seen, except in “specific situations,” BC still refuses to test people without symptoms. If the current testing policy continues to prevail, it will likely be only a matter of time before another tragedy of Holy Family proportions unfolds in BC.
However, as Dr. Michael Schwandt has assured us, “massive and deadly COVID-19 outbreaks in long-term care” are not inevitable. Dr. Schwandt also identified one of the most crucial steps that must be taken to avoid these outbreaks: mass, proactive testing of staff, regardless of symptoms. At the very least, this should be done without delay to contain outbreaks once they have begun. Ideally, staff would be tested on a regular basis to stop outbreaks before they begin. Had this been done at Holy Family, the tragedy that didn’t have to be might not have been.
It is imperative that we do all that we can to prevent similar tragedies in the future. Calculations of cost must not stand in the way of saving all the lives that we can save from here on in. To reduce the cost of testing, BC could consider strategies such as pooled testing, which uses significantly less testing resources, including chemical reagents which have sometimes been in short supply. Whatever it takes to get this done, it must be done without delay. Our current policy has clearly failed to protect our most vulnerable people. A proactive testing strategy is urgently needed.
A petition which calls for precisely this kind of testing has been signed by over 2,000 British Columbians: To Save Lives, We Must Drastically Increase COVID-19 Testing in BC.
Too many British Columbians have already left us before their time, my friends. The people who raised us, cared for us and protected us. They need us now, desperately. Please take a stand.
Sincerely, Ron Hughes