Why has Covid’s fourth wave been so different across Canada?

Jordan When you read the title of this episode and saw that it was about the fourth wave of Covid-19, your reaction and your desire to listen to it probably varied wildly, depending on where in Canada you live. If you view it through the headlines and the numbers, then the story of Covid in Canada this fall has been one of sweeping differences from coast to coast, province to province, even town to town.

News Clips …I have to thank Ontarians they are doing the right things and by having the right actions, they are limiting the spread of this virus…

…people are dying in Alberta at three times Canada’s National per capita rate. The death rate is more than four times higher in Saskatchewan…

…Premier Scott Moe today announced the province is sending six ICU patients to Ontario for treatment…

…Medical officer of Health Doctor Jennifer Russell says the fourth wave has hit New Brunswick hard…

…starting at midnight local time, a circuit breaker took effect in BC’s Northern region. That’s a part of the province where the virus is running rampant and vaccination rates are among the lowest in the country….

Jordan Some of these differences in regional outcomes are obvious. For instance, there was only one province that declared it the best summer ever and dropped basically all restrictions on Canada Day. But some of the differences are more mystifying. Atlantic Canada has been in lockstep on preventing the virus for most of this pandemic. So why are New Brunswick’s cases and hospitalizations spiking to a record level while its neighbor Nova Scotia maintains its solidly low numbers? What did Ontario get right at least so far, that has prevented a large fourth wave, even as it seemed all the ingredients for one were already mixed. And if we’re comparing by regions, does it even make sense to use provinces as the benchmark? Or is the story of Covid’s fourth wave in this country told in much smaller communities one by one across the landscape? What can the science of regional Covid responses and how the virus has responded to them, tell us about the future of this pandemic and when we can at long last declare it over?

I’m Jordan Heath-Rawlings. This is The Big Story. Dr. Raywat Deonandan is a global health epidemiologist and associate professor with the Interdisciplinary School of Health Sciences at the University of Ottawa. Welcome, Dr. Deonandan.

Dr. Deonandan Thank you so much.

Jordan Thank you so much for joining us. I want to ask you first, it seems to me as a layperson that this fourth wave of Covid-19 has just been the most wildly different one from region to region across the country. Is that what you’re seeing as well?

Dr. Deonandan I’m not sure if I agree. It depends on how you want to define different. So this fourth wave is a different way for sure. And it’s characterized by being the wave that is driven by the Delta variant and the wave for which we have widespread vaccinations. So there’s going to be some variation based upon that last point alone. But in the first few waves, we saw a stark divide between most of the country and the maritime provinces, who essentially were going for Covid zero, even though they wouldn’t say so, and the Northern parts of the country were mostly untouched as well. Now we’re seeing outbreaks in every part of the country, but we’re still seeing that divide of maritime and the north versus everybody else.

Jordan That’s really interesting, because one of the pieces that I was looking at drew a pretty clear distinction between what New Brunswick is going through now compared to, say, Nova Scotia next door. Now, I know on the scale of some of the horrific waves we’ve had in larger provinces, it’s not quite the same thing, but it did strike me as just like, those provinces seem to move in lockstep, the whole pandemic, and now it looks entirely different.

Dr. Deonandan Yeah, it does. I’m not sure entirely why. I think it has something to do with some of the policy decisions made in the last few months around one province throwing the borders open a bit more flagrantly than the other ones. The maritime bubble sort of was pierced earlier in this year, and then it became each province for its own. The use of rapid testing has been inconsistent. The use of the mask mandate has been heterogeneous across the maritime region. In general, though, they’re doing better than the rest of the country. But you’re right within the maritime zone, New Brunswick is having the hardest time. Then you’ve got PEI. I love looking at the PEI peak numbers because it looks so strange. You need to inflate the scale so extraordinarily in order to see one or two cases. It looks like some kind of alien language, but that’s been an oasis throughout this entire endeavour.

Jordan That’s an amazing problem to have. If we were having this conversation back in, I’m going to say June here, just before Canada Day, because I’m sure we’re going to talk about what happened out west on Canada Day. But if we were having this conversation in June and I kind of asked you, what are you concerned about for the fall? What do you think we might see in terms of a fourth wave? How close or far away is this from that?

Dr. Deonandan Back then, I was a little naive. I did not anticipate two things. I didn’t anticipate the rigor and voraciousness of the Delta variant and the fact that it would become dominant so quickly. I did not anticipate how slow we would be to accept vaccination even when vaccines arrived on our shores in volume. The third thing I was unprepared for was a bit of a disregard some of our leaders had for the teeth of this virus, and I was naively expecting all those things to tilt in our favor and that we would not have a fourth wave. I was saying this back in May or so. By June I was having my suspicions. So where we are now, I’m surprised. However, I’m pleasantly surprised that we seem to be getting out of the Delta wave faster than some have thought. But again, it comes down to those factors that I mentioned, vaccination rates, the dominance of Delta, and some of the policy decisions made by some leaders.

Jordan I’m going to ask you about those policy decisions kind of across the country as we maybe can go sort of region by region. The first thing that kind of sticks out to me is that through most of the first few waves of the pandemic, we were kind of lumping the responses of the big province conservative premieres Jason Kenney and Doug Ford and Scott Moe together as an approach. But obviously Ontario is faring way better in this fourth wave. How is that?

Dr. Deonandan Yeah, it could be due to a number of factors. First of all, is it right to compare Ideologies across provinces? Maybe it is, maybe it isn’t, I’m not sure. There’s only so much that a provincial leader can do. There is some pushback by the medical establishment, pushback by the population. There are limitations regarding demographics and geography and so forth. So I’m sure there is a large role to be played by the leadership, but I think it often gets overestimated in some analyses. Having said that there is something to be said for a particular kind of biological approach that minimizes the threat of the pandemic that maybe suspects or wants to accept that letting it rip might be a strategy and maybe a government that is more susceptible to the whisperings of the business sector asking to open things up faster than probably we need to.

But the ways in which Alberta and Ontario have bifurcated, have diverged from each other are quite stark. This summer in particular, Ontario did something really good in that I think it was good that they decided not to open schools in June. I think that prevented a particularly bad outcome early on, and that gave us time to get our ducks in order. What ducks? The vaccination Ducks. So Ontario pushed vaccination hard and put together a roadmap that was quite rational in my mind. That roadmap included indicators around vaccine uptake, indicators around the health system capacity, and these indicators would determine which aspects of society would be opened up while we encourage vaccine uptake to a strong degree.

That was not seen in Alberta. Instead, in Alberta, there was an open admission or claim that Covid is over, and this was based supposedly on modelling based on UK data, which was faulty because it assumed that Delta would not be dominant and did not take into consideration the fact that there’s probably a bit more population immunity in the UK because of their really bad experiences with this disease. There was an expectation that Alberta was closer to, quote unquote herd immunity than Ontario was, and as a result, there was not the same push for vaccination. To this day. The vaccination rates and Alberta are amongst the lowest among provinces. So it was not surprising to any expert watching that Alberta would experience the extreme havoc that unfolded in those months.

Jordan When you said a couple of moments ago that it appears and it’s surprising to you, it appears that the Delta wave may be already receding faster than expected. Why do you think that? What evidence is there?

Dr. Deonandan Well, we look around the province and we see that the epi-curve is diminishing. So the K and Epi curve is already coming down. Every single province shows a decline in the incidence rate. So the epi-curve is essentially the number of new cases per day, that curve that we see all the time. It’s no longer exploding out of control. And if you look around the province at the reproduction numbers, which are the average number of new cases produced by an existing case before that case is resolved, and it’s resolved either through recovery or through death. We want to see a number that’s below one, and it’s below one everywhere across the country, except for the Northwest Territories, where it’s hovering around one. So the epidemic seems to be receding quickly everywhere.

Now, that could change. That could change as the weather changes and people’s behaviour changes. But it seems to be, to my mind, the result of a variety of factors. Number one is vaccination. Of course, we have a lot of immune people in the population, maybe not enough to quash the epidemic, but enough to offer some stability and some breathing room. Number two, we’ve learned how to deal with this epidemic, this disease to a very large extent. We know that mask wearing works. We know the distancing works. People are, for the most part, becoming more compliant now than they were previously in the year.

Then we have these other factors, like we have the vaccine passport, which is a dangerous thing to talk about, but we have to talk about it. I think it’s showing its teeth. If we keep the unvaccinated out of super spreading environments, they are not going to be part of super spreading experiences, and they will not cause super spreading events. And we aren’t seeing super spreading events, and we keep businesses open that way. It’s also an incentive to get vaccinated. And we have a slow acceptance by many public health leaders that Covid has a strong airborne component. This is important. As an airborne disease, it can be best attacked by ventilation improvements. So this time around, we see schools with their windows open. We see HEPA filters installed where they can be. We see high quality N95 masks being worn in workplaces. We didn’t see that in previous waves. I think that’s contributing to a rapid stifling of cases. In addition, we have the rapid tests being used in some provinces to a high capacity and in businesses in places like Ontario. And that’s helping to keep infectious people out of super spreading environments. So all these public health tools layered on top of another are showing their teeth at last.

Jordan I’m going to ask this like it’s a leading question I really don’t intend it to be. I’m just curious on your thoughts. Why did it take us until the fourth wave to take ‘Covid is airborne’ seriously?

Dr. Deonandan That is a delicious and problematic question, my friend. I don’t know the answer, except some people suspect that there is a political component to it, and by which I mean a power dynamic associated with it. If you accept that droplet transmission is the sole or extremely dominant method by which Covid is transmitted, then you accept that the responsibility is on the part of the individual to protect themselves and others. So I wear my mask, I keep my distance. I keep a barrier between me and you, et cetera. It’s up to me. If we accept that it’s airborne, then suddenly the responsibility shifts in large part to business owners, to government, to Big Brother, essentially, to invest in ventilation control, especially in schools and large businesses.

And there is a suspicion that maybe that required switch in thinking is enough of a disincentive to the power brokers. I don’t know. That sounds vaguely conspiratorial to me, but there’s also the sense that the flu is droplet transmitted. The common cold is droplet transmitted, so it makes sense that Covid would be. So there may be just a sentiment amongst the infectious disease experts to not want to stray away from what they know, which is the flu in the common cold. And there’s still a divide. By the way, many people do not accept that it’s airborne, but I’m on team airborne. I think it definitely is.

Jordan In terms of if, as you say, the epi-curves have begun to come down and the wave is receding, what comes next? And I’m thinking here, especially in places like Alberta and Saskatchewan, which, while the curve may be trending down, I mean, Saskatchewan patients are being airlifted to Ontario ICUs as we speak. What has to happen next for these provinces to prevent a winter wave? Because this is the time last year, at least. And anecdotally I was up north this weekend and this was the first time where it felt like you had to be indoors and that changes things. Is my understanding.

Dr. Deonandan Good question. What needs to change to prevent another wave? Well, we may not get another wave because of sufficient immunity in the population, and you get immunity in two ways. One is through vaccination, the other is through infection and recovery, and Delta is so transmissible that as one colleague put it, it rages through your population like a tropical storm and leaves in its wake the havoc of misery and death, but also the gift of immunity. So maybe we’ll avoid it simply through mass suffering. But maybe not. There are still a large number of susceptible people in provinces like Saskatchewan and Alberta where vaccine uptake is barely over 60%. And that’s regionally heterogeneous as well. Many regions in those provinces have vaccine uptake numbers less than 50%.

So that in mind, there’s a large number of susceptible people who can still drive further waves. What needs to happen is they need to become immune, and they need to become immune, preferably via vaccination. And one way of doing so is to encourage them via things like the vaccine passport, in addition to doubling down on educational campaign. So what can government do? What can policymakers do? Those things. Create incentives for vaccinations and disincentives against not being vaccinated.

Jordan I’m really curious about what you just said in terms of some smaller communities that are struggling with vaccination rates. And maybe when I began this conversation by kind of approaching the fourth wave as a regional thing through provinces, could it perhaps be that it’s going to be regionally driven down at the community level, where there are these sorts of rural communities that are really hesitant it appears?

Dr. Deonandan Absolutely. The reasons for regional variation are complicated. There are administrative reasons because different governments make different decisions from province to province, from city to city and so forth. There’s also demographic differences. So populations with more young people may not feel the same compulsion to become vaccinated as populations with older people, populations with a greater experience with the disease and ill health may be more motivated than other populations. Populations with more Indigenous people with a history of distrust of the man, might be less inclined.

So it is complicated and it’s going to vary from neighborhood to neighborhood. This is what we know about the unvaccinated. They are geographically clustered and socially linked. They are not evenly distributed across the population. They are heterogeneously distributed, which is why we are always going to see outbreaks exploding seemingly randomly across the country without much of a pattern because of these clusters of nonimmune people. So yeah, absolutely correct that the distribution of vaccine hesitancy and the distribution of susceptibility is down to the neighborhood level, not necessarily the provincial level.

Jordan One of the last things I want to ask you about is just how much of a precipice, I guess we’re on here in Ontario, at least, where cases have been kind of hovering, maybe slowly declining over the past month or so. It’s certainly much better than I think many of us could have hoped for going into this fall. I’m trying to figure out how concerned I should be that that is going to change as we move into, as I mentioned, settings where it’s no longer possible to dine outside or to gather with friends and family outside and everything moves indoors.

Dr. Deonandan Yeah, that is the big question. How concerned should we be? Look, I’m always concerned and I’m concerned because we’ve seen what happened, the first three waves. People don’t seem to learn. Things are a bit different now, though, and they’re different for two main reasons. One is we have vaccination. We have this remarkable nuclear weapon that can get us out of it, if simply, we used it strategically and to high effect. And the second reason we have the administrative tool of the vaccine passport and its relatives. Which means that most of the super spreading opportunities, the formal ones like gyms and concerts and restaurants can be controlled. It’s the informal ones that we don’t really know about. That’s the people gathering in their homes, they don’t require vaccine passports. That’s what you’re talking about, I think. That’s always going to be a concern.

But do keep in mind that because we have lifted the concern from these other formal venues. We can now move public health assets to focus on these home based gatherings. And we can do so even more so when schools get fixed. How do we fix schools? Well we get the vaccination available for the under twelves, and when we have mandates for education workers and for school workers, and we have better ventilation quality in schools and rapid tests deployed across all schools. When that happens, we can move even more public health assets to manage the expected community outbreaks. But I’m a weirdly optimistic guy at this point. And what I’m seeing is so much vaccine uptake in some key areas, like where I live in Ottawa, it looks like 90% of the over twelves are vaccinated now, and we may get close to Saturation at some point. But if we can do that well, then we keep the crisis out of the health care system, and that’s really all we can ask for. Once it’s out of the healthcare system, then we can manage this like an endemic disease, which is not ideal but manageable.

So how concerned should we be? Let the experts be concerned about this, and the people should follow public health guidance, get on with their lives, and just be cognizant that there is a risk and be responsible. But don’t panic. Things are trending sort of the way we expected them to be. And I think that sometime early next year we should be out of the wave aspects of this epidemic here in Canada.

Jordan Well, then, in terms of letting the experts worry, let me ask you one last practical question. And that is just I remember at this time last year going into Halloween, parents were hoping, what can we do? Can kids have a night? It’s been so hard for them. And I feel like we know so much more this year and we have vaccinations and so many more people are safe that Halloween should be fine. But for myself as a parent and all the other parents listening, can kids go out and trick or treat as normal?

Dr. Deonandan Yeah, I’ve got a small child as well, and my child isn’t old enough to trick or treat. But I would take my child trick or treating if they were old enough. And as long as you stay outside, you don’t go into people’s homes. You’re wearing a mask anyway. So I think it’s more or less okay. Last year we were concerned about fomites still. Surface transmission, which is not happening with Covid. We didn’t understand aerosol transmission. We didn’t know the power offered by being outdoors. What I’m most concerned about with Halloween is people having Halloween parties, especially young people. That’s what’s going to drive any outbreaks if they do occur. But for kids going door to door, I think it’s mostly fine.

Jordan That’s a wonderful note to end it on. Thank you, Dr. Deonandan.

Dr. Deonandan Thank you very much.

Jordan That was Dr. Raywat Deonandan, Epidemiologist at the University of Ottawa.

That was the big story for more from us, including lots and lots of COVID stories, maybe none as optimistic as this one, you can head to thebigstorypodcast.ca. You can find us on Twitter at @TheBigStoryFPN. You can talk to us anytime via email at thebigstorypodcast@rci.rogers.com [click here!]. You can also find us in every single podcast player on the market. At least I think so. I have not personally checked them. But if you find one, as always, that we are not in, send us a link. We will thank you personally when we include ourselves.

Thanks for listening. I’m Jordan Heath-Rawlings. We’ll talk tomorrow. Back to top of page