From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

British Columbia’s Response to the COVID-19 Pandemic: The August Update (2020)

Brandon Tang^1,2, Sara Allin^2,3, Greg Marchildon^2,3

¹Department of Medicine, University of British Columbia
²North American Observatory on Health Systems and Policies
³Institute of Health Policy, Management and Evaluation, University of Toronto

Relative Success

British Columbia (BC) has continued to demonstrate relative success in its pandemic response, with Provincial Health Officer Dr. Bonnie Henry receiving international praise for her strong and effective leadership. As of 30 July 2020, the total number of COVID-19 cases per 1,000,000 population in BC (691) was considerably lower than Canada overall (3,059) and a range of international jurisdictions including the United States (13,374), Italy (4,081), and Spain (6,104). Mortality rates in BC per 1,000,000 (38) have also remained an order of magnitude lower than the Canadian average (236), the United States (455), Italy (581), and Spain (608). In fact, in early May, the BC government reported the lowest COVID-19 mortality of any jurisdiction in North America or Europe with a population greater than five million.

Staged Reopening Plan

Successful implementation of public health measures coupled with data-driven decision making are previously described enablers of the BC pandemic response. Likewise, these principles have informed the province’s four-step plan for staged reopening of the economy and public life, released on 6 May 2020. Models from this report suggest that BC could safely increase the population’s rate of contact to 60% of pre-COVID-19 levels, while still maintaining a flat rate of transmission. This would allow for nearly double the amount of social interactions, which were reduced to about 30% of normal when public health regulations were at their strictest.

Phase 1 (mid-March to mid-May) of the reopening plan ended in BC on 18 May 2020, marking the end of peak stringency in public health measures. During Phase 2 (mid-May to mid-June), previously restricted health services were reinitiated, including elective surgeries, dentistry, and physiotherapy. Many businesses, office-based worksites, and restaurants also reopened with additional safety and physical distancing measures in place. On 24 June 2020, the province transitioned into Phase 3 (mid-June to present), in which non-essential travel within BC was permitted with the reopening of tourism services such as provincial parks and hotels. Plans were also announced for a full return to in-class instruction for K-12 schools in early September. While the reopening plan remains in Phase 3 as of early August, clear criteria have been outlined which would enable a return to pre-pandemic norms during Phase 4, such as large group gatherings and international travel – these include broad vaccination, widespread immunity, and evidence of successful treatments for COVID-19.

Reflections on the BC Response

Along with Ontario and Saskatchewan, British Columbia was one of the first Canadian provinces to launch a staged reopening plan. Accordingly, their relatively advanced progress in the pandemic response may offer insight for other Canadian and international jurisdictions.

The long-term care (LTC) sector has been hit disproportionately by the pandemic in BC, but considerably less so than in other parts of Canada. As of 1 June 2020, residents of LTC facilities and retirement homes accounted for 85% of overall COVID-19 deaths in Canada, 88% in Quebec, 81% in Ontario, although only 55% of deaths in BC.

Both administrative and engineering controls contributed to mitigation of the impact of COVID-19 within LTC facilities in BC. For example, BC implemented regulations to control the flow of people through LTC facilities relatively early in the pandemic. On 17 March 2020, LTC visitors were restricted to essential visits only, then on 27 March 2020, BC was the first province to limit the movement of health care workers between LTC facilities to reduce potential transmission. In addition, a greater number of LTC facilities within BC have modern infrastructure with fewer four-bed units, thereby promoting physical distancing between patients. In fact, 73% of LTC residents in BC resided in single-occupancy rooms as of January 2018.

Testing volume was lower in BC than in other provinces, with the third-lowest testing rate per 1,000,000 (42,608) amongst all Canadian provinces and territories as of 28 July 2020. This testing volume was significantly lower than provinces with a similar or larger population, including Alberta (125,314 per 1,000,000), Ontario (137,435), and Quebec (91,667). Overall, however, the limited testing in BC appears to have been compensated for by effective and timely public health measures to successfully contain the transmission of the virus.

Despite careful implementation of staged reopening within BC, recent modelling data demonstrate a trend toward rising COVID-19 case volumes, with community transmission linked to several provincial tourist destinations. As of 20 July 2020, the number of reported cases exceeded the threshold for sustained spread, although ongoing projections remain uncertain due to low volumes to extrapolate from. Communication regarding the importance of physical distancing has been clear and consistent, with social interaction and travel guidelines developed provincially. However, with a potential summer surge in COVID-19 and flu season looming in the autumn, ongoing monitoring of case volumes and adjustment of physical distancing measures will be required until widespread vaccination or effective treatment becomes available.

British Columbia’s Response to the Coronavirus Pandemic – Original post (April 2020)

Brandon Tang¹, Sara Allin^2,3, Greg Marchildon^2,3

¹Department of Medicine, University of British Columbia
²North American Observatory on Health Systems and Policies
³Institute of Health Policy, Management and Evaluation, University of Toronto

Background and Scope

British Columbia (BC) is the third largest and westernmost province in Canada, with a population of 5,071,336. The largest city in the province is Vancouver, which is widely regarded as a global financial center and international travel hub.  The first case of COVID-19 was reported in BC on 26 January 2020 in a returning traveller from China. By 11 March, the day the World Health Organization (WHO) declared COVID-19 a pandemic, there were 46 reported cases in the province. In the following days, public health measures were rapidly implemented between 14 to 21 March, with concurrent health systems planning and capacity building. As of 17 April, the incidence of new cases in BC had plateaued and begun to decline, with the epidemic curve demonstrating relative success compared to other Canadian provinces and a number of jurisdictions outside of Canada including the United States, Italy, and Spain.

Public Health Measures

Data published by the BC Ministry of Health suggest that public health measures in BC were implemented earlier and more rapidly than the rest of Canada and a range of international jurisdictions. Compared to Canada as a whole, these interventions were assessed as relatively “stringent” by the Oxford Stringency Index, although did not reach the peak stringency of international jurisdictions such as Italy and France. On 12 March, a day after the WHO declared COVID-19 a pandemic, the BC government issued an advisory against non-essential international travel, requested returning travellers to self-isolate for 14 days, and prohibited events larger than 250 people, later lowering this to a threshold of 50 people. On 17 March, a public health emergency was declared by the BC government and K-12 schools were closed. Three days later, all dine-in food services were prohibited, with only takeout and delivery options permitted. Shortly after physical distancing policies were introduced, the incidence of new cases peaked on 25 March and has declined thereafter.  As of 21 April, the number of confirmed cases per 100,000 people in BC (33.8) was lower compared to Canada overall (104.2) and considerably lower than harder hit countries such as the United States (238.0), Italy (299.7), and Spain (428.2). The mortality rate in BC per 100,000 (1.72) was also considerably lower than the Canadian average (5.1), the United States (12.9), Italy (39.9), and Spain (44.6).

Health Systems Planning and Capacity Building

Since 2012, the majority of hospitals in BC have been operating at over 100% capacity. Given this baseline, system-wide strain and early models from 27 March predicting the rate of new COVID-19 cases in BC, measures were taken to increase capacity for acute hospital care, bolster the health workforce, support virtual care, and ensure the availability of medical supplies. Hospitals created capacity by cancelling non-essential procedures and surgeries, as directed by the government on 16 March, and decanting lower acuity patients to long term care facilities that have been repurposed as temporary hospitals. Moreover, recognizing the vulnerability of patients in long-term care, policy changes were implemented that only permitted essential visits, while also restricting movement of health care workers between different care facilities. To expand the available physician workforce, on 19 March, the College of Physicians and Surgeons of BC announced the creation of temporary emergency registration for eligible physicians, such as recently retired physicians and senior internal medicine residents approaching graduation. Additionally, decades of stagnation in virtual care adoption were deftly reversed, with the development of expanded physician billing codes, offering comparable compensation for in-person and virtual care services, which were available for both primary care and specialist physicians. Finally, to address perceived shortages in personal protective equipment and other medical supplies for frontline workers, the BC government established a new Provincial Supply Chain Coordination Unit to coordinate goods and services distribution with industry.

Socio-Economic Impact

Exacerbated by the high cost of living in BC, COVID-19 has contributed to both individual and systemic financial strain. For instance, a BC Chamber of Commerce survey found that 77% of businesses have been negatively impacted by the pandemic. Recognizing this, the BC government released a COVID-19 Action Plan on 23 March, which introduced financial and policy support for affected individuals and businesses, including: income support, policies to prevent rent increases and evictions, and childcare support for essential service workers. After the pandemic, the plan designates CAD $1.5 billion in provincial funding for economic stimulus. In addition, specific policies have been developed to support vulnerable populations including the creation of spaces for homeless individuals to self-isolate, and enhanced medical transportation to better serve the province’s remote, indigenous, and rural communities.

Reflections on the BC Response

The early and diligent enactment of public health measures in BC appears to have been successful, as evidenced by lower per capita cases and deaths from COVID-19 relative to other Canadian provinces and international jurisdictions. Acute care capacity was effectively increased by decanting patients and decreasing elective procedures and surgeries. As of 14 April, critical care occupancy was 45.7% province-wide, with 681 critical care ventilators available. Hence, while public health measures have prevented a surge in new cases and hospital admissions, BC has maintained enough critical care capacity should the pandemic eventually mirror or even surpass the highest Italian-modelled curves.

The BC government provides compelling data which suggest that public health action has effectively flattened the epidemic curve. The stringent and early implementation of public health measures appear to have promoted physical distancing, as correlation with Google Mobility Reports demonstrates that public mobility in workplaces, transit areas, and retail shops decreased after their introduction. Finally, examination of the BC epidemic curve suggests a temporal correlation between enactment of public health measures between 14 to 21 March, and the subsequent plateau in new COVID-19 cases. Overall, an overarching strength of the BC response to COVID-19 has been its use of epidemiologic models, and transparency in publicly sharing these models ahead of other Canadian provinces such as Alberta, Ontario and Quebec. A strong example of data-driven capacity planning in BC was forecasting critical care needs based on the epidemic curve from Northern Italy, where these resources faced maximal strain. In addition, the government appears to be closely monitoring ongoing epidemiologic data and making rational decisions based on these trends, such as the stringency of physical distancing policies.

While early results from the pandemic response are promising, some reports suggest potential areas for improvement. Early communiques from the Office of the Provincial Health Officer were occasionally conflicting, such as whether health care providers returning from international travel were required to self-isolate. More recently, there has been a lag in the reporting of certain epidemiologic data from a major health authority involved in COVID-19 care, for unclear reasons. Finally, the number of COVID-19 tests conducted per 100,000 in BC (1,260.9) is relatively low compared to the Canadian average (1,573.5) and international jurisdictions such as Italy (2,452). Without testing at scale, it is challenging to identify asymptomatic carriers and prevent community transmission of disease. Perhaps recognizing this, while BC initially focused testing on only high risk individuals and outbreaks, a new policy was introduced on 8 April which enabled any individual with symptoms of COVID-19 to be tested.

Effective implementation of public health measures and health systems planning has contributed to a BC epidemic curve far below projections originally generated by the provincial government. In terms of next steps, the BC government announced on 17 April that certain public health restrictions may be reduced in May if the incidence of new cases continues to decline. However, new models have been developed to track how case incidence may change as physical distancing decreases. Overall, the early, data-driven, and stringent public health measures taken in BC have contributed to a successful pandemic response, and may offer valuable insights for provincial, national, and international jurisdictions still in the midst of the pandemic.

Useful Links

North American Observatory on Health Systems and Policies. Pan-Canadian COVID-19 policy response monitor: British Columbia; April 2020. Available from: https://ihpme.utoronto.ca/research/research-centres-initiatives/nao/covid19/

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