It's a story that is tragically familiar in Ontario: a resident of a long-term care home gets COVID-19 and they live in a crowded shared room with multiple other vulnerable elderly people, making it very difficult to control the rapid spread of the virus throughout the facility.
Only in Hong Kong, the ending is different.
The independent commission into the COVID-19 crisis in Ontario's long-term care homes has been hearing testimony recently from public health experts in Ontario and Hong Kong on how the province has failed to protect the vulnerable residents of its long-term care homes.
Dr. Terry Lum, associate director of the Sau Po Centre on Ageing at The University of Hong Kong, recently walked the commission through how the region has managed to keep the COVID-19 fatalities in its care homes far lower than in Ontario, despite some of the same pre-pandemic vulnerabilities.
One major factor is the region has been far better at controlling community spread. Hong Kong has recorded 7,291 cases and 114 deaths overall, with approximately half of the population of Ontario, which has recorded 136,631 cases and 3,916 deaths. As of Friday, 2,460 of the Ontarians who died were residents of long-term care homes.
Another key difference Lum highlighted is that when a resident contracts COVID-19 they're taken to the hospital for treatment and isolation and their roommates are moved into a quarantine centre for two weeks.
"So this [is] because the infectious rate is so high," said Lum. "If you have one person ... with the virus still stay in the nursing home, because the worker will be in and out, no matter how careful ... they are working, the virus will spread ... rapidly within that nursing home."
As soon as a case is detected, an official with the department of health and an infectious disease specialist from the university will visit the home, said Lum. If they find the home is especially old and the ventilation is poor, making infection prevention and control impossible, the entire home would be evacuated to a quarantine centre, he said.
In Ontario, it's a far different story — residents aren't usually moved from the homes when an outbreak occurs and transfers to hospital are relatively rare, even for COVID-positive elderly residents.
There have been repeated calls for Ontario to "decant" residents from old long-term care homes by moving them to a safe place. That's because, as in Hong Kong, many residents in older homes live in cramped ward rooms and there isn't enough space to isolate COVID-positive patients and perform proper infection prevention and control. But with few exceptions, Ontario leaves residents in their long-term care homes and attempts to isolate them there, sometimes with limited success. Lum said that is not allowed in Hong Kong.
Ontario has seen the consequences — long-term care homes have had explosive outbreaks where all of the residents were infected and, in some homes, one in three have died.
Long-Term Care Minister Merrilee Fullerton has acknowledged the problems controlling the spread of disease in older homes, but said the decision to move residents out is complex and residents can't just be moved "like widgets" as they have a moral right to live in their homes.
The Hong Kong government, according to Lum, quickly established quarantine centres in tourist hostels.
The commission has heard testimony from local experts about the province's failure to move residents to a safe place, showing how different Hong Kong's strategy has been.
Dr. Nathan Stall, a geriatrician with the Sinai Health System and University Health Network, laid out his research to the long-term care commission, including one study that showed long-term care residents with COVID-19 were far less likely to be transferred to the hospital prior to death than those who live in the community of the same age.
He found only about 15 per cent of the COVID-positive long-term care residents who died in March and April were transferred to hospital — a time when the province was very concerned about a crisis in hospital occupancy that did not come to pass. More than 40 per cent of long-term care residents were transferred to a hospital prior to death in June and July, when the pandemic was at a low point and hospitals had more direct involvement in long-term care homes.
Conversely, hospitalizations among LTC residents who died of COVID19 varied substantially from a low of 15.5% in March-April (peak of wave 1) to a high of 41.2% in June-July (nadir of wave 1).
Additionally, women were less likely than men to be hospitalized prior to death.
4/6 pic.twitter.com/Kyd7Ven3CX
— Nathan Stall (@NathanStall) November 16, 2020
Even though there was no official policy in Ontario denying hospitalizations for long-term care residents there were media reports about those transfers being discouraged and the commission had heard testimony from long-term care operators to that effect, Stall said.
"I think this is important because that very well may have contributed to the large concentration of death we saw in the first wave, and people were not being transferred to hospital who not only may have benefited from medical care that may have saved their life, but also people were not being transferred for just basic care when homes were in crisis, and people weren't being transferred for palliative care to help them die with dignity during the first wave when homes were totally overwhelmed," said Stall.
In another study, Stall found that the size of outbreaks in Ontario's first wave was twice as large in for-profit than in those in non-profit homes, largely because more for-profit homes have older design standards and ward rooms.
"And I would argue that leaving homes crowded like this in the face of surging transmission is just leaving them as lame ducks," he told the commission.
Hong Kong took other important steps, some of them taken as a result of the SARS crisis, which killed more people there than anywhere else that saw an epidemic, including Toronto. Lum described how the experience of SARS caused people to become extremely worried about COVID-19 quickly and to take action, including wearing masks before the government made that directive, to protect themselves and protect their health-care system.
Hong Kong's long-term care homes were better prepared in other ways. Lum said the government requires every home to have a nurse trained in infectious disease control. That is especially important, according to Lum, because when the pandemic hit the staff knew what to do and didn't desert their posts, as was the case in other places, including Ontario.
Like Ontario, Hong Kong has also been struggling with a staffing shortage in long-term care. But in early February, homes converted their half-time positions into full-time to prevent staff from working multiple jobs and moving between homes. Lum said this wasn't a decision made by the government, but by the long-term care operators who knew from their experience with SARS what would be needed.
Lum also described something akin to the "iron ring" Ontario promised: a regime of disinfecting workers upon entry, keeping staff home until they can be tested if there is a case in the highrise they live in, and keeping non-essential people out of the homes — although like in Ontario, this has resulted in loneliness for residents.
Hong Kong also struggled to procure personal protective equipment, but Lum said it was common for homes to have a three-month supply of PPE because it was used frequently before the pandemic for protection against other diseases. The government then stepped in to provide PPE to all homes.
The commission has heard testimony that the Ontario government was slow to mandate mask-wearing in homes, left homes mostly on their own to procure their own supplies and prioritized hospitals over long-term care in what was provided.
Ontario's failures
In another interview, an epidemiologist and outspoken critic of the Ontario government outlined nine fundamental errors that he said "resulted in the tragedy that unfolded" in the province's long-term care homes.
Dr. David Fisman, a professor at the Dalla Lana School of Public Health, said the first of those was the denial by the government's health leadership that COVID-19 was transmitting in the community in March. To illustrate that, Fisman read an angry email he'd written on March 24 in reaction to a press conference at which Associate Medical Officer of Health Dr. Barbara Yaffe had denied there was community transmission in Toronto.
At that time, he said, he was seeing cases at the Toronto hospital where he works were the source of transmission was a Bay Street Tax seminar and a rave — clear cases of community transmission — and that the denial of community transmission likely led to early outbreaks in long-term care.
"What [Dr. Yaffe] is doing is awful. It undermines public health messaging and is patently false," he'd written. "We have a long term care outbreak now where staff worked with mild respiratory symptoms because it couldn’t possibly be COVID. These [personal support workers] joked about it. But they hadn’t travelled and didn’t know anyone with COVID, so according to [Dr. Yaffe] that’s unlikely COVID."
"I’m assuming you’re all up to speed on what mortality of COVID looks like in long term care ... that is coming," he wrote at the time.
Among the other failures Fisman identified were those that allowed staff to continue to move between homes, spreading the disease. That includes not following British Columbia's example in that area and not creating "economic security and dignity for part-time workers at long-term care, which would obviate the need to work at multiple facilities."
Fisman said that overall, the province failed to operate under the precautionary principle that is supposed to guide its actions in emergencies — to err on the side of caution when in doubt. It is another lesson from the SARS epidemic and Fisman said the province failed it in setting policies for long-term care and other areas, including keeping migrant workers safe in their bunkhouses.
"You know, I think I'm regarded by some of my colleagues as coming across as a bit of a hothead because I've been speaking out quite forcefully about this," he said. "But if we set out a principle that's supposed to guide how we practice in a crisis and then we ignore it time and time again, you know, what is one to say?"
But despite that, he said that the second wave in long-term care, so far, has not escalated as rapidly as the first wave did and suggested some lessons have been learned.
"So looking at the numbers, I don't regard them as positive or really even acceptable," he said, "but I regard them as a vast improvement on what happened to us in the spring."
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