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The first wave of COVID-19 infections in Canada began in January 2020 and wound down about 5 months later.1 This Viewpoint describes the Canadian experience and response to the larger second and third waves of COVID-19 infections during the period September 2020 through August 2021 (eFigure in the Supplement).
Provincial and Territorial Responses
Canada’s 10 provincial and 3 territorial governments have jurisdiction over most health care issues. The provincial chief medical officers of health issued directives on mask mandates, testing, and contact tracing. The premier of each province (the equivalent of a US state governor) had the power to issue broad directives on all issues, including business closures and stay-at-home orders for the entire population. Provincial governments were responsible for managing testing capacity, school policies, practices in long-term care (LTC) facilities, and acute care activity (eg, pausing scheduled surgeries).
The third wave of COVID-19 infections overwhelmed the capacity of acute care hospitals, particularly intensive care units (ICUs) in Ontario, Alberta, and Manitoba. Although Canada did not experience the high rates of infection that occurred in the United Kingdom and United States during the first wave, by the third wave the per capita rates of infection in Alberta and Manitoba reached the highest level of any state or province in North America, and the rates in Ontario and Saskatchewan were not far behind. In Ontario and Manitoba, some patients who required ICU care were transferred from hospitals where they sought care to other distant locations.
Lack of ICU capacity in each jurisdiction was a major variable that led governments to enact drastic policies like stay-at-home orders and school closures. For example, in April when patients with COVID-19 occupied nearly 600 of Ontario’s approximately 2000 ICU beds (1300 with ventilator capacity), it triggered stay-at-home orders and shut down the economy.2,3 By May, 920 of Ontario’s ICU beds were occupied by patients with COVID-19. Several provinces closed in-person learning. Compared with the first wave during which public adherence was high, stay-at-home orders were more contentious. Mobility and personal contact were not nearly as reduced by government mandates in the second and third waves.4 Mask mandates were introduced in July 2020 and most of the public was willing to wear masks indoors thereafter.
The third wave was driven by the more transmissible Alpha (B.1.1.7) variant. Improvement in infection control practices in LTC facilities after the first wave varied across the country, with Quebec showing significant improvement, and Ontario almost none. Deaths in LTC facilities and retirement homes declined substantially following the first rollout of vaccines, which began in December 2020 and prioritized residents and staff in LTC settings. The vast majority of residents of LTC facilities were vaccinated by the middle of February 2021.5 As such, the third wave had little effect on LTC facilities’ residents, who had accounted for most COVID deaths in the prior 2 waves.6 The Atlantic provinces fared very well during this period by restricting travel from outside the region and swiftly responding to new cases with community-based rapid testing to limit outbreaks.
Federal Government Response
The federal government was responsible for 3 main issues: border control, vaccine procurement, and approval of drugs and vaccines. On February 22, 2021, the government instituted a controversial policy of requiring all international travelers to Canada who arrived by air to be quarantined for 3 days in hotels chosen by the government, to receive COVID-19 tests before and after arriving in Canada, and to complete their 14-day quarantine at home. The implementation of this policy was clumsy, with many people spending considerable time booking rooms, high costs, lack of food, and cases of COVID-19 transmission in the quarantine hotels. Some people simply refused to comply, accepting the fine instead. A loophole was created by allowing people to fly to border airports in the United States (eg, Buffalo and Seattle) and enter Canada by land.
Health Canada approved the first vaccine (Pfizer-BioNTech) on December 9, 2020, and vaccinations were administered to health care workers that same month. Initially, provinces adhered to the dosing interval of 21 and 28 days established by Pfizer and Moderna but when it became clear that adequate vaccine supply would not be forthcoming during the second wave (due to several events, such as when the United States did not export any vaccines, and Pfizer refurbished its plant in Belgium delaying scheduled deliveries), the National Advisory Committee on Immunization (NACI) recommended a dosing interval of up to 16 weeks. All provinces switched to that interval although some groups (eg, Indigenous peoples of Canada, some patients with cancer, patients with organ transplants, and people receiving dialysis) were given second vaccine doses at 21 and 28 days in some regions.
After a relatively slow start, Canada has achieved higher rates of both first and second vaccine doses than most countries. For instance, by August 5, 72% of the total Canadian population had received at least 1 dose of a COVID-19 vaccine and 61% were fully vaccinated, compared with 69% and 58% in the United Kingdom, 65% and 54% in Italy, 65% and 49% in France, 58% and 50% in the United States, and 46% and 33% in Japan, respectively.7
Canada approved the AstraZeneca vaccine for emergency use on February 26, 2021.8 NACI initially recommended using the vaccine only for people younger than 65 years (because of few older participants in vaccine randomized trials), then recommended this vaccine for everyone older than 18 years, and subsequently recommended the vaccine only for people older than 40 years because of concerns about vaccine-induced immune thrombotic thrombocytopenia (VITT).9 Federal and provincial leaders assured the public that the vaccine was safe and actively promoted a slogan: “Take the first shot you are offered.” However, when the rate of VITT was estimated to be roughly 1 in 60 000 people and Canada had reached a total of 13 cases (in April 2021), provincial governments altered their approaches. Even though no cases of VITT had been found after administration of mRNA vaccines to date, Canada was in the middle of its worst wave and the supply of mRNA vaccines was insufficient to meet demand. As a result, provincial governments continued to recommend the AstraZeneca vaccine, until NACI recommended that mixing vaccines was acceptable on May 30, 2021. By June 2021, most of Canada had abandoned using the AstraZeneca vaccine and eventually donated 17 million doses to the COVAX program.
By the end of July, the total new cases per day had declined to about 600 in all of Canada, but began to rebound in early August as the Delta variant became predominant and public health measures were lifting. As of August 14, Canada’s 7-day average of daily new cases was 1608 and rising. Provinces took different paces for lifting restrictions, mostly based on metrics such as health care system capacity, vaccine uptake, and community COVID-19 burden (eg, cases, hospitalizations, and deaths). For example, Alberta and Saskatchewan lifted virtually all public health COVID-19 prevention measures in July 2021, and in August, Canada allowed fully vaccinated Canadians and US residents to enter the country without quarantine.
Canada remains vulnerable in several areas. Children younger than 12 years are not yet eligible for vaccination and could be a potential source of outbreaks in the fall, and governments have done little to expand relatively limited ICU capacity so far.10 The next year will see Canada addressing new challenges that will require some difficult government decisions and individual choices, including implementing vaccine mandates, vaccine “passports,” and the upcoming campaign to vaccinate children. Canada’s significant access to and uptake of vaccines will most likely help lessen the effects of a fourth or subsequent waves of COVID-19, but disparate interprovincial public health policies and limited critical care capacity continue to pose challenges.
Corresponding Author: Allan S. Detsky, MD, PhD, Mount Sinai Hospital, 600 University Ave, Room 429, Toronto, ON, M5G 1X5, Canada (firstname.lastname@example.org).
Published Online: August 23, 2021. doi:10.1001/jama.2021.14797
Conflict of Interest Disclosures: Dr Detsky reported receiving consulting fees as a member of the Telus Medical Advisory Committee for COVID planning, being on the Scientific Advisory Board of Bindle Systems, and owning stock in Pfizer, AstraZeneca, and Johnson & Johnson. Dr Bogoch reported serving as a consultant to BlueDot, a social benefit corporation that tracks emerging infectious diseases, and to the National Hockey League Players’ Association.
Additional Contributions: Kenneth Elo, BComm, prepared the figures, for which he was compensated.
eFigure. New weekly confirmed COVID-19 cases and deaths per million population
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Detsky AS, Bogoch II. COVID-19 in Canada: Experience and Response to Waves 2 and 3. JAMA. 2021;326(12):1145–1146. doi:10.1001/jama.2021.14797
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