It is time for Canada to take COVID-19 border controls seriously
In March, as SARS-CoV-2 spread globally, the federal government invoked the Quarantine Act to pass a series of orders addressing international travel into Canada. The land border with the United States was effectively closed to all but “essential workers” and restrictions on who can enter the country were implemented, along with exceptions to these rules.
With the identification of the novel UK mutation, much public attention has been focused on our borders. Doug Ford, Premier of Ontario, spent two days lambasting the federal government for the volume of international passengers arriving at Pearson International Airport in Toronto, and what he believes are minimal checks for these passengers. Seemingly in response, on December 22, Patty Hajdu, federal Minister of Health, and Bill Blair, Minister of Public Safety and Emergency Preparedness, defended the Liberal government’s response, stating that that the government would be using the 72-hour window of restricted UK arrivals to “examine the evidence” around its border policies, while claiming that less than 2% of all cases in Canada are travel related and Canada’s border controls are among the most stringent in the world.
In Ontario, the second wave of COVID-19 has produced case numbers so high that contact tracing has effectively collapsed in some areas, with only high-risk, largely congregate outbreak situations receiving such attention. This has resulted in many of Ontario’s second-wave cases having no known confirmed source: 65% for Toronto Public Health and 49% for the combination of Toronto, Peel and York.
It is thus impossible for the federal government to make accurate claims as to the percentage of cases attributable to international travel. Moreover, in response to a Freedom of Information request I submitted, the Public Health Agency of Canada (PHAC) has acknowledged not having any records on to the number of passengers who have tested positive; the breakdown between citizens and permanent residents on one hand and those falling into the exapanded categories of allowed traveller on the other; or the number of individual passengers contacted in qurantine checks. Bill Blair claimed that one million checks have been made thus far. However, over one million travellers returned before the end of March; what of those who have arrived in the nearly nine months since? We have not been able to make even a single check -in with each quarantined passenger, let alone multiple checks over the two-week period.
Canadian leaders have developed the unfortunate habit of benchmarking our performance against those doing poorly, such as the United States, rather than those who have found success. It is not clear to what countries Ministers Hajdu and Blair compared Canada’s border controls as they were not identified, but it is abundantly clear that ours are seriously lacking when compared to those of countries that have successfully contained this virus to a manageable number of cases, defined here as that which allows robust contact tracing and isolation. This group of nations famously includes Australia and New Zealand, but also Japan, South Korea, Taiwan, Vietnam, Thailand, Singapore as well as Hong Kong and, yes, China. In fact, while lockdown stringency has different within and among these jurisdictions, a vigilant approach to the identification and isolation of imported cases has been common to all.
Korean Air summarizes these international border control regimens. They have utilized three general strategies: tight restrictions on who can enter the country, managed quarantine and mandatory testing. The first of these is obvious, and has generally restricted arrivals to citizens and permanent residents, occasionally truly immediate family. The third is similarly obvious, encompassing some combination of proof of negative test before arrival (including IgM antigen tests in the case of China), plus mandatory testing upon arrival and prior to the exit from quarantine.
Managed quarantine refers to the quarantine of travellers at designated facilities, usually hotels, for the duration of the quarantine period. This essentially eliminates the risk of imported cases spreading to household contacts and the broader community; the CDC has demonstrated the secondary infection rate among household contacts to be as high as 53%, far higher than originally thought in the spring. It further allows for the identification of onset of symptoms in travellers after arrival and lengthening of quarantine as appropriate. Designated facilities tend to be located at the point of arrival. In New Zealand, this required managed quarantine in Auckland before going anywhere else in the country. Travellers themselves are usually required to pay for associated hotel quarantine costs. The integrity of managed quarantine was so prioritized in Australia that during Melbourne’s second wave all international flights were diverted out of Victoria and the number of arrivals sharply cut to 4000 per week to maintain the integrity of the system.
In contrast to Australia, Canada’s federal government made it easier for more people to arrive from abroad during our second wave. On October 2 the list of allowed travellers was expanded to now include the extended family of those in “committed dating relationship” with a citizen or permanent resident, for example. Doug Ford has noted 64,000 weekly international arrivals at Pearson alone, where travellers can hop on connecting flights and subsequent public transportation to reach the eventual quarantine destination, which could be an apartment shared by others whose mobility isn’t restricted during the quarantine period. There is no direct supervision of these travellers for subsequent onset of symptoms, instead relying on an honour system of electronic reporting. There is no requirement for negative testing prior exiting quarantine, thus only those travellers who develop symptoms (usually required for testing) and choose to get tested will be identified. This is incongruent with our knowledge of asymptomatic transmission and, for instance, the absence of paid sick leave acting as a disincentive for testing in the case of quarantine households shared with essential workers who would have to miss work. Comparing our measures to the above, it is difficult to take Patty Hajdu and Bill Blair seriously.
PHAC has been updating a list of flights that after arrival have been identified as carrying passengers who have tested positive for SARS-CoV-2. For any given date, it updates the list of identified flights for up to 14 days after arrival, and flight dates are stricken from the online list after 14 days, ostensibly because that is the length of the quarantine period. Unfortunately, it does not publicly maintain this list online, but released the list in response to my FOI request. It also does not release or even maintain records on the number of passengers who have tested positive.
As of December 21, roughly (for reasons explained above in regards to PHAC reporting) 1140 international flights have been identified as carrying passengers who have tested positive for COVID. Due to an absence of mandatory testing, this mainly reflects only those passengers who later became symptomatic (or who did not disclose symptoms during travel) and voluntarily sought testing.
After an initial rush of travellers returning to Canada, there was a lull before a gradual increase in the number of monthly affected flights. Canada introduced immediate family travel allowances at the beginning of June, and a further broadening of exemptions at the beginning of October. The PHAC data show a sharp jump in the number of identified flights in the summer just as community transmission was decreasing in major jurisdictions; in fact, Toronto Public Health data show cases attributable to travel exceeding community transmission for weeks in the summer.
There are clear increases identification of affected flights following the two federal government announcements expanding travel allowances to Canada.
Canada has imported cases from forty-two countries, with ten countries each serving as the origin of twenty or more flights: USA (333), Mexico (145), Germany (103), India (76), UK (72), France (59), Turkey (45), Netherlands (42), UAE (27), Qatar (23).
As mentioned, the initial repatriation efforts allowed passengers to arrive at airports across the country however since March 18 international flights have largely been redirected to the four international airports in Montreal, Toronto, Calgary and Vancouver. Since the beginning of the pandemic Toronto has received 49% of all affected flights (562), Montreal 22% (252), Calgary 13% (152) and Vancouver 11% (143). Since May, Toronto has received 50%, Montreal 23%, Vancouver 13.5% and Calgary 12.6%.
The data on destination airport become more interesting when further broken down by time. As mentioned, there is no mandatory testing regime for arrivals in Canada. However, on November 2, the federal and Alberta governments launched a pilot program offering voluntary testing to passengers arriving at Calgary, which essentially consists of an initial test preceding a 48 hour quarantine, with further quarantine eliminated for those who test negative and who agree to take a second test days later. This program thus provides a natural experiment on the effect of an organized voluntary testing program on the identification of infected passengers, as there is no reason to suspect that relative patterns or volume of air travel changed among the four major airports subsequent to that date.
In the five months preceding the Calgary pilot program, 552 affected flights were reported by PHAC, with Toronto receiving 56.5% (312), Montreal 23% (127), Vancouver 14.8% (82), and Calgary 4.7% (26).
Since the launch of the program, PHAC has identified 370 affected flights, with Toronto receiving 39.7% (147), Calgary 25.1% (93), Montreal 23.5% (87), and Vancouver 11% (41). Thus, after introducing a testing program, nearly four times the number of affected flights to Calgary were identified in seven weeks as compared to the previous five months. Calgary went from having just 8% of Toronto’s affected flight total to 63%, despite comparatively small passenger volume that does not include flights from six of the top ten sources of imported cases to Canada.
Given the absence of evidence of any significant relative change in flight patters or volumes among the four airports, it is likely that this shift in relative standing of Calgary among the airports is attributable to the presence of testing, i.e absence of a similar testing program depressed the totals from the other airports relative to Calgary’s. It’s reasonable to assume that Calgary’s identified flight figure still represents the same same 4.7% of the national total that would result with equivalent testing at the four airports. Thus, had the Calgary testing program been simultaneous mirrored across Montreal, Toronto and Vancouver we likely would have identified about 1980 flights nationally after November 2, as compared to the official figure of 370 flights provided by PHAC: roughly 1118 to Toronto (officially 147), 455 to Montreal (officially 87), and 293 to Vancouver (officially 41).
There are those who will cite initial data from the Calgary pilot to claim that few travellers are testing positive. While Calgary is reporting a fairly low percent positivity in its pilot, it does not receive flights from the breadth of high-risk nations seen at the other three airports. Similarly, the Air Canada sponsored program at Pearson is both restricted to terminal one and the consenting of participants in only English or French, thereby excluding so many travellers as to make the study’s representation of the airport’s passenger flow as a whole questionable.
Let us return to Bill Blair’s claim of 2% of total cases being attributable to international travel. From December 18–24 Ontario reported 16143 cases, 2% of this total amounting to 323 cases. Given the reported volume of 64000 weekly international travel at Pearson, this would equate to a 0.5% positivity rate were all international travellers tested. However Calgary has (confusingly) reported 1.48% of primary tests positive and 0.69% of secondary tests positive in it’s pilot (despite not receiving flights from origins like Turkey, UK, France, India, UAE or Qatar) and even the Air Canada-sponsored, methodologically flawed test at Pearson has reported around 1% positivity. If just 2% of travellers to Pearson are positive, that would amount to 1200 primary cases in international travellers, or 8% of the total weekly new cases reported in Ontario from December 18–24, excluding any secondary transmissions from the travellers to household contacts during quarantine and beyond. This would total a much higher percentage of total cases in weeks past when Ontario case numbers were lower. It is thus not useful for federal politicians to utilize national travel statistics to describe the situation in Ontario given the unique volume of international travel and diversity of flight origins at Pearson International.
It is clear that the absence of testing is leading to the failure to identify potentially the majority of imported cases, who represent a high risk for transmission to household contacts in shared quarantine spaces, and subsequent community transmission. This has already been demonstrated spectacularly in Calgary, where a passenger who initially tested negative in the pilot and was released from hotel quarantine subsequently transmitted the virus to at least four household contacts before herself testing positive on the second test. By then a household contact had in turn transmitted it to a coworker. The overburdened contact tracing system in Ontario exacerbates these risks.
Canadians have suffered tremendously over the past year. More than 14000 have died, often without family by their side. Many more will have long-lasting effects of infection. Necessary health care has been postponed. Healthcare workers are exhausted, and more PSWs — heroes, all — have died of COVID in Ontario than police officers on the job nationally. Nearly one million jobs remain lost without recovery and thousands of businesses have failed. A series of “lockdowns” have been ineffective as feckless politicians invent a health vs economy dichomoty that does not actually exist. At some point our elected officials need to clearly articulate a set of priorities and make the necessary difficult decisions.
We need decisive action to reduce case numbers to manageable amounts. The federal government should immediately move to limit, with hard caps if necessary, the number of international arrivals. Even though citizens and permanent residents abroad have had nine months to return, those who have not done so still have the right to enter. The same cannot be said for the convoluted set of add-ons to the list of allowed travellers. If these exceptions could be added in more benign times, they can surely be removed in these dire times. To prevent household and community transmission, a managed quarantine program in hotels, at traveller expense, should be introduced at minimum for those who cannot quarantine without exposure to other household contacts, if not all travellers. This could serve as an economic boon to a beleaguered hospitality industry. We need mandatory testing on arrival and prior to the exit from quarantine. The specifics of this should be determined by experts rather than a commercial airline with a vested interest in minimizing the duration of quarantine.
It is December, not March. We now have examples of what works and these measures have been implemented in every major jurisdiction that can claim a measure of success in fighting this pandemic. We should have the humility to seek advice from these nations, and seek to join this group of peer countries rather than continuously looking at the responses in the United States and Europe. While such measures may seem harsh, they are not as harsh as having to “visit” an admitted relative via iPad or shuttering a family business, and only affect those choosing to travel to Canada by air almost a year into a global pandemic. Our current patchwork of pronouncements has created the ethical absurdity of Ontario residents not being allowed to see family from across town for Christmas while being allowed to have relatives step off a plane after a transatlantic flight and head over for dinner. This is an insult to the millions who face mobility and social restrictions domestically and who have sacrificed so much this year.
Doug Ford (along with provincial leaders elsewhere) is right to be upset with the federal response to our borders but he must accept criticism for the present state as his government has always maintained the ability to implement stricter testing and quarantine measures than those imposed by the federal Liberals, let alone being entirely responsible for the ineffective broader measures inacted in Ontario. Changes are needed and if the federal government, which can generously be described as slow to respond to evidence during the pandemic, won’t make those changes, provincial leaders must.