Meeting Summaries of the CSA Expert Panel on COVID-19

As part of the response to the COVID-19 pandemic, the Chief Science Advisor of Canada created the Expert Panel on COVID-19 to advise her on the latest scientific developments relevant to COVID-19. This information assists the CSA in providing current, cross-disciplinary and independent advice to the Prime Minister and government.

On this page:

 
 

Overview of Discussions

Meeting #1 of the CSA Expert Panel

Held by teleconference on March 10, 2020

 

The following discussion reflects evidence and scientific knowledge up to March 9th.

 
 

Summary

  • Canada’s Chief Science Advisor (CSA) convened a meeting with a panel of multidisciplinary experts.
  • The meeting objective was to share updates on the latest science around COVID19 in areas of disease modelling, social behaviour, biomedical and clinical research and identify gaps for Canada.
  • Disease spread is context-dependent. International data on COVID19 infection and fatality rate may be biased or inapplicable to Canada. We need Canada-specific data and analysis to inform decision-making.

Participating Experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)
 

Disease Modelling

 
  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital
  • Babak Pourbohloul PhD, University of British Columbia
 

Risk and Behavioural Sciences

 
  • Daniel Krewski PhD, University of Ottawa
  • Louise Lemyre PhD, University of Ottawa
  • Steven Taylor PhD, University of British Columbia
 

Biomedical and Clinical Sciences

 
  • Maziar Divangahi PhD, McGill University
  • Gary Kobinger PhD, Université Laval
  • Joanne Langley MD, Dalhousie University
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Caroline Quach MD, Université de Montréal
 

Other

 
  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)
 

Disease Modelling

 
  • Mathematical modelling can be used to inform understanding of infection spread and the services needed to respond to COVID19.
  • Disease spread is context-dependent and will be different between countries, and between rural and urban populations.
  • Models that have been used to understand the spread of previous infectious disease outbreaks can be used for COVID19.
  • Data on travel itineraries and mobile devices exist and could be put to use for monitoring compliance to self-isolating and social distancing recommendations. Other countries are currently using these data.
  • Uncertainties can negatively impact the effectiveness of modelling, these include the lack of precise information on rate of infection in the population, rate of hospitalization and case fatality.
  • Given the knowledge as of March 9, there is a wide range in estimates for R0 (the basic reproduction number, defined as the expected number of secondary cases produced by a single typical infection), making it uninformative for optimal policy.
  • In order to develop reliable estimates of COVID19 transmission rates in Canada, modelling researchers need access to public health data, i.e. when patients were likely exposed, time of symptom onset, contact tracing information, sources of infection (domestic or imported) and information about negative tests.

Social Behaviour and Communication

  • Understanding social attitudes, risk perceptions and compliance to guidelines is essential for all stages of disease containment and prevention of spread.
  • Public Health England (PHE), done in collaboration with academic institutions, conducts surveys on messaging, risk perception, attitudes and barriers to social distancing. These include testing acceptability and preparedness to social distancing, school closure, restrictions on travel, and events.
  • Experts are not aware of such efforts in Canada. Such data, collected regularly and segmented (age, gender, education, location), would provide a basis for behavioural recommendations.
  • From experience in previous outbreaks, timely and transparent communication to the public is key for positive response and compliance to public health recommendations.
  • With respect to risk perception, research on COVID-19 does not appear to be linked up with provincial or federal public health agencies in Canada.

Diagnostics

PCR Testing Capacity

  • Diagnostic tests are presently carried out using a DNA-based assay called real-time reverse transcriptase polymerase chain reaction (rRT-PCR).
  • Patient specimen are accepted for testing if the individual meets criteria for a person under investigation or probable case for COVID-19.
  • For the flu, routine testing is recommended. Same can be considered for COVID-19, for two reasons (1) protection of the healthcare system and (2) for obtaining Canadian data on infection rates. This may require surge capacity.

Serological Testing

  • A serological test against COVID-19 is a blood test that can detect antibodies that a patient produces against the virus. The advantage of serological testing is that it can detect the virus after the infection has been cleared.
  • Serology is important for understanding disease spread in the community, especially when it comes to patients with very mild symptoms that may not be currently picked up by PCR testing. That, in turn, will inform the likelihood of recurrence and the impact of future COVID-19 infections.
  • Discussion on the need for serological testing is ongoing at the World Health Organization (WHO).
  • In BC, acute and convalescent serology samples of patients tested for COVID-19 will soon become available.

Home-testing Kits

  • It was noted that Gates Foundation-funded home-testing kits may become available soon, the healthcare system needs to be prepared to with deal with the impacts this may have on clinic visits and further tests.

Research and Clinical Data Sharing

  • Rapid sharing of COVID-19 data and samples is important to inform decisions during the epidemic.
  • Facilitating this process is an ongoing challenge in Canada and needs to be addressed.
  • CIHR has been working to streamline the IRB (Institutional Review Board, an ethics review committee that has to approve proposed research prior to it being conducted) processes. Additional messaging from CIHR on this subject would be beneficial.

Patient and Healthcare Worker Safety

  • COVID-19 complications are respiratory, so the shortage of ventilators is anticipated.
  • Canada lacks manufacturing capacity with respect to medical protective equipment (e.g. surgical masks and N95s).
  • There are efforts to test the efficacy and safety of nasal oxygen (concerns include potential spread of the virus by aerosol), but currently only one site (Sunnybrook) is doing it. This testing could be extended to other locations.

International Context

  • Importance of remaining connected internationally around consistency of actions and messages.
  • Canada should be ready for early phase testing of future vaccine candidates.

 


 

 

Overview of Discussions

Meeting #2 of the CSA Expert Panel

Held by teleconference on March 13, 2020

 

The following discussion reflects evidence and scientific knowledge up to March 12th.

 


 

Summary

  • The objective of the meeting was to share the latest scientific updates on COVID-19 and identify gaps in the infrastructure needed for vaccine and therapeutic development as well as in communicating effectively with the public.
  • There is an urgent need for improved coordination of Canada’s COVID-19 response in the areas of research, data-sharing, clinical trials, ethics approval processes and communications.

Participating Experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital
  • Babak Pourbohloul PhD, University of British Columbia

 

Risk and Behavioural Sciences

 

  • Daniel Krewski PhD, University of Ottawa
  • Louise Lemyre PhD, University of Ottawa
  • Steven Taylor PhD, University of British Columbia

 

Biomedical and clinical sciences

 

  • Maziar Divangahi PhD, McGill University
  • Gary Kobinger PhD, Université Laval
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Supriya Sharma MD, Health Canada

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

Infrastructure for Vaccine and Therapeutic Development

 

  • Canada has limited capacity to produce clinical grade vaccines.
  • Canada has strong vaccination and immunization networks that have great capacity for conducting clinical trials at all 3 phases.
  • There is a potential for researchers and companies that do not have a working relationship with Health Canada to have delays in making progress towards anti-COVID-19 therapeutics/vaccine.
  • To accelerate the path for potential COVID-19-related vaccines and therapeutics, companies and researchers need to have an easy and accelerated path to Phase-1 trials.

Coordination of Research and Clinical Trials

Disease Modelling

  • A group at the Public Health Agency of Canada National Microbiology Laboratory is looking at disease modelling from a Canadian perspective (initially using COVID-19 data coming out of China).
  • As the number of COVID-19 cases continue to grow, Canada-specific data becomes increasingly critical for accurate disease modelling. As of March 12, researchers lack access to Canadian COVID-19 public health data.

Animal Models

  • In the scenario where therapeutics that have already been approved do not show efficacy in clinical trials against COVID-19 (currently conducted in China and elsewhere), novel compounds and therapeutics would need to be investigated using animal models.
  • There are only a few Containment Level 3 (CL3) laboratories approved to work with the SARS-CoV-2 virus in Canada. This limits the intensity of research that can be done with the SARS-CoV-2 virus. Proactive certification of CL3 laboratories to work with SARS-CoV-2 virus would facilitate animal model work.

Clinical Trials

  • Canada may soon have sufficient cases of COVID-19 to run informative clinical trials. The next few weeks is important for planning and getting organized to conduct these trials, before the healthcare system and professionals are at capacity.
  • There is an excellent system in place for clinical trials for intensive care unit patients, but not for less severe patients. The challenges are:
    • Organizing the clinical trials.
    • Getting the clinical trials approved.
    • Acquiring the resources or shifting existing resources to run the clinical trials.
  • There may be a need to recruit research and healthcare professionals from other disciplines (e.g. oncology) to help run clinical trials as infectious disease specialists are likely to be mobilized to the frontlines.
  • The challenges of recruiting multiple hospitals into clinical trials include the facilitation of contracts, data-sharing agreements and money transfers. Some of these issues are occurring at the working level.
  • CIHR has been praised for reaching out to research institutions and asking them to streamline the IRB (Institutional Review Board - an ethics review committee that has to approve proposed research prior to it being conducted) processes for COVID-19 projects. Another reach-out from CIHR to research institutions on this topic would be encouraged.

Coordination for Communications

  • Understanding social attitudes, risk perceptions and compliance to guidelines is essential for all stages of disease containment and prevention of spread.
  • Canada would benefit from monitoring risk perceptions, attitudes and barriers towards proposed interventions (e.g. physical distancing) from Canadian public.
  • Effective communication of why governments are taking some measures and not others, and providing the supporting evidence (e.g. results of modelling) may facilitate compliance.

 


 

 

Overview of Discussions

Meeting #3 of the CSA Expert Panel

Held by teleconference on March 17, 2020

 

The following discussion reflects evidence and scientific knowledge up to March 16th.

 


 

Summary

  • The objective of the meeting was to share the latest scientific updates on COVID-19 and discuss potential research challenges.
  • Messaging to both the research community and the general public needs to be clarified and reinforced.

Participating Experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital
  • Babak Pourbohloul PhD, University of British Columbia

 

Risk and Behavioural Sciences

 

  • Daniel Krewski PhD, University of Ottawa
  • Louise Lemyre PhD, University of Ottawa

 

Biomedical and Clinical Sciences

 

  • Maziar Divangahi PhD, McGill University
  • Matthew Gilmour PhD, Public Health Agency of Canada
  • Gary Kobinger PhD, Université Laval
  • Joanne Langley MD, Dalhousie University
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Caroline Quach MD, Université de Montréal
  • Supriya Sharma MD, Health Canada

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

Participating Guests: (present for the first 20 min of the call)

 

  • The Honourable Navdeep Bains, Minister of Innovation, Science and Industry

 

Expert Panel’s Feedback on the COVID-19 Response

 

Connecting Researchers to Government

  • Scientists are generating a large amount of data, however, it is not always clear what the mechanism is to contribute information to a centralized government location.

Researcher Access to Public Health Data

  • Disease modellers need data to determine the effectiveness of physical distancing measures.
  • An app-based approach could be considered to monitor adherence to physical distancing measures since, given the knowledge as of March 16, current modelling suggests a prolonged period of public health measures (8-12 months).

Canada's Capacity for Therapeutic Development

  • Canada has the capacity to bring two made-in-Canada vaccines through all phases of clinical trials within 12 months. Researchers and companies are seeking a clear signal on whether the government will support these efforts.
  • It is important for Canada to develop its own capacity for bringing vaccines from research, to clinical trials, and then to market for this pandemic and for future epidemics.

Communicating with the Public

  • Pre-announcements of COVID-19 public health measures would make planning life easier for all and minimize anxiety.
  • It anticipated that there will be a need to address additional consequences of physical distancing, such, increase in domestic violence and mental health concerns.
  • More explicit explanations for Public Health Agency of Canada's actions would be helpful for maintaining public cooperation:
    • Explaining "flattening the curve" and that by flattening the curve we extend the duration of the pandemic.
    • Explaining to travellers the meaning of voluntary self-quarantine and how to plan ahead.
    • With regard to boarder screening, invite returning travelers to provide an email/phone number to receive updates on COVID-19 and/or to be invited to participate in surveys.

The "Herd Immunity" Approach

  • The UK had cited "herd immunity" as part of its approach to responding to COVID-19. This means, in the absence of a vaccine, allowing the virus to spread through a population until most individuals have survived the infection and are immune. At that point, the outbreak dies out due to a lack of susceptible hosts.
  • The expert panel members agree that there are significant unknowns about COVID-19 and the public health risks, and that "herd immunity" would not be an appropriate approach for Canada. The concerns expressed include:
  • Given the knowledge as of March 16, there is not enough known about the immune response induced by SARS-CoV-2 and the length of post-infection immunity is poorly understood.
  • Canada healthcare capacity (equipment, hospital rooms, and personnel) would be severely challenged by letting COVID-19 run its course through the population. We also need to consider the long-term mental and physical wellness of frontline healthcare workers.
  • Physical distancing favours a lower exposure dose.
  • Canada has Northern communities for whom a widespread outbreak would be particularly challenging to manage physical distancing and other measures are needed to flatten and delay the infection peak to give time for further research and therapy development. If the healthcare system is overwhelmed, clinical scientists will not be available to conduct their research.
  • Herd immunity is the eventual goal, but through use of vaccines against COVID-19.

Serological Testing and Rsearch Challenges

  • As vaccine clinical trials start rolling out, serology becomes increasingly important to identify immune status of the Canadian population (i.e. testing the blood for presence of antibodies against the COVID-19 virus).
  • The Public Health Agency of Canada's National Microbiology Laboratory is working to establish serology testing capacity.
  • There is already some substantial serological research looking at the potential of asymptomatic transmission, using acute and convalescent seraFootnote 1.
  • Registry/bio-banking of serum from people tested for COVID-19 would be an important tool to understand immune status of the population, once serology testing becomes available. This information will be crucial for clinical decisions, modelling and vaccine rollouts.
  • There may be mixed messages coming from hospitals and universities that could be interpreted as clinical research being discretionary, including research on COVID-19. Research staff are being directed to work remotely, resulting in workforce shortage. This is especially a problem when serological sampling is involved as personnel need to be on-site collecting and processing the samples.
  • Efforts on serological testing would benefit from research ethics approvals being fast-tracked.

Development of Therapeutics

  • Funding is one of the limiting factors.
  • All levels of government, as well as public and private philanthropic organizations, could be encouraged to work together on the goal of therapeutic development.
  • The concern was raised that many organic chemists are working on developing potential therapeutic molecules but do not have access to funding or shared resources and platforms for bio testing and scaling up.
  • It is important for Canada to develop its own capacity for antiviral research.
  • Strategies and needs for further therapeutic developments will be discussed at the next call.

Artificial Intelligence and Data-sharing

  • The US has put out a call to the AI and machine learning community to develop new text and data mining techniques that can help researchers answer high-priority scientific questions related to COVID19 and facilitate more efficient data-sharing.
  • Canada has extensive expertise in AI that could be put to use to help manage COVID-19 crisis.

 


 

 

Overview of Discussions

Meeting #4 of the CSA Expert Panel

Held by teleconference on March 20, 2020

 

The following discussion reflects evidence and scientific knowledge up to March 19th.

 


 

Summary

  • The objective of the meeting was to receive updates on federal government response and to share latest scientific updates on COVID-19 research.
  • A need for a one-stop-shop to coordinate COVID19 research in Canada was highlighted during the call.

Participating experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital
  • Babak Pourbohloul PhD, University of British Columbia

 

Risk and Behavioural Sciences

 

  • Daniel Krewski PhD, University of Ottawa
  • Louise Lemyre PhD, University of Ottawa
  • Steven Taylor PhD, University of British Columbia

 

Biomedical and Clinical Sciences

 

  • Maziar Divangahi PhD, McGill University
  • Matthew Gilmour PhD, Public Health Agency of Canada
  • Gary Kobinger PhD, Université Laval
  • Joanne Langley MD, Dalhousie University
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Caroline Quach MD, Université de Montréal
  • Supriya Sharma MD, Health Canada
  • Cara Tannenbaum MD, Université de Montréal, Health Canada Departmental Science Advisor

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

Participating Guests: (first 40 min of the call)

 

  • Stephen Lucas PhD, Deputy Minister of Health Canada

 

Update on Federal Government Support for COVID-19 R&D

 

  • Deputy Minister Stephen Lucas provided an update on three major areas of focus for the government:
    • Supporting research, development, and manufacturing.
      • An additional $25.8 million has been added to the initial research investment of $27 million, administered through CIHR.
      • NRC has launched a new COVID19 Challenge Program that is open across sectors and seeks to address Canada's needs in diagnostics, therapeutics, disease-tracking and protective equipment. This is folded into NRC's Industrial Research Assistance Program to expedite development and facilitate procurement.
      • ISED will lead, via the Strategic Innovation Fund, on directly supporting businesses to rapidly scale up production or re-tool their manufacturing lines to develop candidate therapeutics, vaccines, and critical medical supplies.
    • Modelling the impacts of COVID-19 on health systems in the provinces and territories to better understand the gap between hospital capacity (ICU beds, respirators, medical personnel) and anticipated need.
    • Assessing the efficacy of and compliance to public health measures such as border screening, self-isolation and physical distancing.
  • The expert panel provided suggestions on each of the areas of focus:

Supporting Research, Development, and Manufacturing

  • Some expert panel members suggested changes that could be made to the competition process of COVID-19 research funding, including that funding be available on a rolling basis in order to better meet evolving research priorities.

Modelling the Impacts of COVID-19 on Health Systems

  • A permanent modelling infrastructure in Canada would be helpful for facilitating coordination, collaboration, and data-sharing among modellers. While a central location would be needed to store and share data, de-centralization of the modelling work would enable more modellers to be involved and better meet local and regional needs.
  • Statistics Canada Research Data Centres could potentially help with storing sensitive data.
  • Key modelling questions for the next stage of the outbreak include: the extent of community spread, number of COVID-19 patients hospitalized and admitted to intensive care (ICU).

Assessing the Efficacy of and Compliance to Public Health Measures

  • Canadian anonymized travel and mobile data are available for use in modelling and analysis.
  • Modelling could be supplemented with survey data. Previous studies show that approximately 80% of people are willing to volunteer their information if assured that they can give consent at every stage.
    • CIHR has significant experience following patient cohorts (e.g. the elderly, pediatric cancer patients) over longitudinal studies. Randomized surveys could be administered within a population to gain better understanding of the community transmission and evolution of the outbreak.
  • It may also benefit Canada to also look internationally for models of public health recommendations and compliance.

Scientific Updates

SARS-CoV-2 mode of transmission

  • A recent NEJM publication indicated that SARS-CoV-2 can survive for up to 3 hours in the air causing many to interpret that the virus is "airborne".
  • The experts explained that the study in question tested the viability of aerosolized SARS-CoV-2 in experimental condition, which is not fully reflective of real-world conditions:
  • Humans don't typically generate aerosols as homogeneous as the ones in this study (other biomaterials would be shed along with the virus).
  • While air transmission is plausible at close distances, given the knowledge as of March 19, available evidence indicates that it is not the main source of transmission.
  • As of March 19, in the small number of cases where healthcare workers have had potential exposure to aerosols generated by patients, no infections have been reported.

Effectiveness of Masks in Infection Prevention

  • A recent publication provides some evidence of the positive impacts of masks in stemming disease spread in South Korea and Singapore.
  • Current public health recommendations are based partly on existing evidence that masks are ineffective against the spread of influenza.
  • As evidence is generated on mask use, if a change in recommendation becomes warranted, it would be important to provide a clear reason for the change. Understanding precedes behavioural change.

Risk Communication to the Public

  • Government has moved away from using the terminology of "low" or "high" risk in public communications, focusing instead on the increased risk for vulnerable individuals and defining who they are. The expert panel welcomed this change in communication strategy.
  • Experts noted that risk perception researchers generally stay away from referring to levels of risk (e.g. low, medium, high) because there is no benchmark for these.
  • There could potentially be a second wave of infection, and the public needs to be prepared for this scenario. It would be helpful for exit strategies from the current public health measures to be framed in the possibility of a second wave.

Citizen Participation in COVID-19 Response

  • Experience from past disasters support that engaging the public in action, in a safe manner, will contribute to overall adherence, solidarity, and wellbeing.
  • One way to engage the public is through donation campaigns, which could help fill funding gaps, increase public awareness and preparedness, increase a sense of community, and alleviate distress by providing positive actions for people to participate in.
  • Another way could be to engage the public in e-volunteering campaigns, harnessing the talent and time of those not working, notably the youth.

Coordination of Research Projects

  • One way to better meet Canada's needs in research, sample storage, and animal testing could be to proactively provide expedited certification for Containment Level 3 (CL3) laboratories to work with SARS-CoV-2.
  • A one-stop-shop could help to coordinate all COVID-19 research in Canada and promote cross-disciplinary collaborations.
  • It may be helpful for the federal government to outline the key research questions that they need answered. Some of the questions may be addressed by researchers not presently working on or benefiting from COVID-19 funding.

 


 

 

Overview of discussions

Meeting #5 of the CSA Expert Panel

Held by teleconference on March 24, 2020

 

The following discussion reflects evidence and scientific knowledge up to March 23rd.

 


 

Summary

  • The objective of the meeting was to share the latest scientific updates on COVID-19 therapeutic development, and identify gaps and opportunities
  • Efforts are underway to better coordinate COVID-19 research in Canada through CanCOVID platform.

Participating experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease modelling

 

  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital
  • Babak Pourbohloul PhD, University of British Columbia

 

Risk and behavioural sciences

 

  • Daniel Krewski PhD, University of Ottawa
  • Louise Lemyre PhD, University of Ottawa
  • Steven Taylor PhD, University of British Columbia

 

Biomedical and clinical sciences

 

  • Maziar Divangahi PhD, McGill University
  • Matthew Gilmour PhD, Public Health Agency of Canada
  • Gary Kobinger PhD, Université Laval
  • Joanne Langley MD, Dalhousie University
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Supriya Sharma MD, Health Canada
  • Cara Tannenbaum MD, Université de Montréal, Health Canada Departmental Science Advisor

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

COVID-19 research coordination

 

  • The potential benefit of a one-stop-shop for COVID-19 research in Canada has been raised by the expert panel.
  • Dr. Cara Tannenbaum, Departmental Science Advisor at Health Canada, has been in discussions with U15 to establish an online platform for coordination of COVID-19 research response.
  • A steering committee is being set up for a “CANCOVID forum,” and a platform is anticipated to be generated shortly.

Therapeutic development in Canada

Animal models

  • VIDO-InterVac in Saskatchewan is conducting COVID-19 research in ferrets and hamsters. Ferrets shed the virus and have a mild respiratory phenotype in a manner that recapitulates what is observed in human patients. The National Microbiology Laboratory and the Canadian Food Inspection Agency are jointly pursuing animal testing including a mouse model that expresses the human form of ACE2 (the receptor that SARS-CoV-2 binds in order to infect host cells).
  • Other Canadian Containment Level 3 (CL3) laboratories, especially those with animal facilities and high-throughput testing, could be proactively contacted and provided with instructions for expedited certification to work with SARS-CoV-2.
  • In addition to animal testing, human challenge trialsFootnote 2 in young adults (as is done in influenza research) could be among the options considered.

Regulatory process

  • Health Canada is moving to streamline and fast-track regulatory processes of pharmaceutical development and clinical trials, while maintaining safety and accountability. The focus right now is on diagnostics, therapeutics, and low risk products (hand sanitizers, personal protective equipment).
  • Health Canada is prioritizing all clinical trial applications, some approved within 48 hours.
  • Requests to access existing pharmaceutical drugs for clinical trials has been difficult due to the low number of cases in Canada, but this is starting to change.

Clinical trials

  • A collaborative effort by researchers running clinical trials for major anti-therapeutics would be an appropriate approach, since data from small trials are difficult to interpret.
  • It would be beneficial for Canadians to join the World Health Organization’s global mega-trial on the most promising COVID-19 treatments (Solidarity trial), wherever possible.
  • A more targeted approach for coordination would be helpful, at least in the early stages. Some expert panel members suggest having a separate dedicated discussion on how to best align and coordinate clinical trials in similar patient population with leaders in clinical trials and Health Canada.

Communication with the public

  • The experts support using the term “physical distancing” rather than “social distancing” in public messaging. They also identified common misconceptions about physical distancing that could benefit from clarification:
    • That physical distancing measures apply only to strangers
    • That the effects of physical distancing on the COVID-19 case count will be seen immediately
  • Germany launched a COVID-19 tracking mobile app that notifies individuals if they have been near someone who tested positive for the virus.

 


 

 

Overview of Discussions

Meeting #6 of the CSA Expert Panel

Held by teleconference on March 27, 2020

 

The following discussion reflects evidence and scientific knowledge up to March 26th.

 


 

Summary

  • The objective of the meeting was to discuss current evidence on using face masks for preventing viral transmission among the general population.
  • The evidence on the effectiveness of face masks among the general population lacks consensus. Given the knowledge as of March 26, it is clear that symptomatic individuals should wear surgical masks to protect others. Given increasing evidence of asymptomatic transmission, the use of protective masks in public spaces may be helpful including as part of deconfinement strategies. The present shortage of medical grade masks for healthcare professionals creates significant concerns about recommending them for general use.

Participating experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital
  • Babak Pourbohloul PhD, University of British Columbia

 

Risk and Behavioural Sciences

 

  • Daniel Krewski PhD, University of Ottawa
  • Louise Lemyre PhD, University of Ottawa
  • Steven Taylor PhD, University of British Columbia

 

Biomedical and Clinical Sciences

 

  • Deborah Cook MD, McMaster University
  • Matthew Gilmour PhD, Public Health Agency of Canada
  • Gary Kobinger PhD, Université Laval
  • Joanne Langley MD, Dalhousie University
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Supriya Sharma MD, Health Canada
  • Cara Tannenbaum MD, Health Canada

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

Participating Guests: (first 30 min of the meeting)

 

  • Simon Kennedy, Deputy Minister of Innovation Science and Economic Development (ISED)

 

ISED Support of Canada’s COVID-19 Response

 

DM Simon Kennedy provided an update on ISED’s COVID-19 response efforts in three major areas (this work is happening in collaboration with Health Canada, Public Health Agency of Canada (PHAC) and Public Service and Procurement Canada):

  1. Rapid procurement of equipment and personal protective equipment (PPE):
    • Checking existing stockpiles, verifying whether they meet the needs, then procuring.
    • They are making a significant effort to expedite reviews and approvals of equipment, as long as it is efficient and responds to PHAC’s needs.
    • There is significant effort on the regulatory side to expedite reviews and approvals of PPE, hand sanitizers, swabs, suits, and other related items.
    • Non-conventional sources are also being considered, e.g. 3D-printed face shields.
  2. Building domestic manufacturing capacity:
    • Re-tooling existing manufacturing to produce supplies necessary for pandemic response.
    • ISED and other departments are supporting re-tooling of complex PPE with funding and technical support.
    • Further, ISED is working to migrate supply chains for these products to Canada.
    • This is easier for some products (eg. hand sanitizers) and harder for complex PPE (eg. ventilators).
  3. Supporting science, research and innovation
    • ISED is providing funding for international and domestic initiatives working on COVID-19 vaccines and antibodies.
    • Since Canada currently does not have the capacity to produce 30 million doses of vaccine in a few months, investing in Good Manufacturing Practices (GMP) facilities is the best option (eg. NRC’s Human Health Therapeutics facility).
    • ISED is identifying labs and firms with potential and providing resources, e.g. AbCellera (therapeutic antibodies) and Medicago (vaccine candidate).

Comments from the expert panel:

  • Expedited procurement should be applied to vaccines and therapeutics, not just equipment.
  • Scale-up of vaccine manufacturing is possible without building factories – bioreactors can be brought to GMP standards to help with the scale-up.
  • Canada could provide important leadership in disease modelling and real-time analytics, but investment is needed in a permanent infrastructure.
  • Since most information regarding COVID-19 and applications for emergency response benefits are available online, access to telecommunications in rural communities needs improvement.

Utility of Face Masks for the General Population

Public health recommendations on using face masks for general population during COVID-19

  • The WHO recently reviewed their recommendation and continues to recommend against the use of masks at the community level because there is a global shortage.
  • Most western countries do not recommend mask use for the general public, citing limited data to prove its efficacy as well as its scarceness.
  • Canada’s public health authorities recommend against the use of masks among the general public.
  • The CDC is actively exploring the usage of masks at the community level, including multi-layer home-made masks.
  • China recommends that people "at moderate risk" should wear surgical masks.
  • Hong Kong recommends that even healthy people wear masks when using public transport or when in crowded places. It is suggested that Hong Kong has unreleased data indicating masks reduce COVID-19 spread by mildly symptomatic people by 30%.
  • South Korea implemented masks as a public health intervention in addition to physical distancing.

Available evidence for and against the effectiveness of face masks among general public

  • There is conflicting evidence around the effectiveness of masks in preventing disease transmission.
  • A systematic review and meta-analysis on the effectiveness of non-pharmaceutical interventions to prevent influenza transmission did not find a significant protective effect by face masks. Regular hand hygiene provided a significant protective effect.
  • A study in Nature Medicine (in press) shows that masks prevent transmission of human coronavirus, but not specifically SARS-CoV-2.
  • Given the knowledge as of March 26, evidence suggests that when a mask is worn there is a general reduction in particles shed around the person wearing a mask – this applies to all viruses because it is due to particle filtering. However, there is no evidence that this translates into reducing viral transmission to others. This is because we don’t know yet exactly how transmission happens and through which route.
  • An Italian study compared the transmission rate within a high-risk community in Italy (did not wear masks) to an “equivalent” community in Japan (wore masks), and found a lower transmission among the Japanese.
  • In the CBRNE (Chemical, Biological, Radiological, Nuclear and Explosive) context, a classified study shows that the use of masks and gloves by the public during decontamination of a biological agent was not effective and increased exposure when compared to no mask/glove control.
  • Future studies might become available in the coming weeks and months with regards to the effectiveness of using face masks among the general population for curbing COVID-19 spread.
  • As more evidence becomes available, the utility of face masks in the general and high-risk population (e.g. elderly, people with pre-existing conditions, etc.) may be re-examined. Wearing masks may be a useful tool for the exit strategy, provided sufficient supply of masks is secured.

Other relevant factors

  • Given that COVID-19 virus is likely transmitted by asymptomatic and low-symptomatic individuals, masks may prevent spread from these individuals.
  • New modalities in respiratory support are increasing opportunities for COVID-19 patients to generate aerosols, further increasing the need for masks for healthcare workers.
  • There is a shortage of PPE, including masks, for healthcare workers.
  • Healthcare workers are professionally trained to use masks, while the general population is not. It is especially important to properly put on and take off the mask (donning and doffing).
  • Masks and other protective equipment are essential for healthcare professionals and they should be prioritized.
  • Health Canada’s position on dealing with mask shortage:
    • Expired N95 masks can be used if they pass inspection.
    • Sterilization and reuse options to be examined
    • Homemade masks are not regulated medical devices. Cloth masks may not filter small particles, like viruses.

Overview of Discussions

Meeting #7 of the CSA Expert Panel

Held by teleconference on April 3, 2020

The following discussion reflects evidence and scientific knowledge up to April 2nd.

 


 

Summary

  • The objective of the meeting was to discuss areas in need of attention and blind spots in COVID-19 response as well as data we should be collecting to guide recovery strategies / easing containment measures.
  • Areas of attention include diagnostic testing, rates of compliance with government recommendations, as well as mental health services.

Participating Experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital
  • Babak Pourbohloul PhD, University of British Columbia

 

Risk and Behavioural Sciences

 

  • Louise Lemyre PhD, University of Ottawa
  • Daniel Krewski PhD, University of Ottawa
  • Steven Taylor PhD, University of British Columbia

 

Biomedical and Clinical Sciences

 

  • Deborah Cook MD, McMaster University
  • Maziar Divangahi PhD, McGill University
  • Gary Kobinger PhD, Université Laval
  • Joanne Langley MD, Dalhousie University
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Supriya Sharma MD, Health Canada
  • Cara Tannenbaum MD, Health Canada

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

Updates to the Expert Panel

 

  • To help address specific questions from Health Canada, the CSA has assembled two focused groups: An Expert Group on Health Systems and an Expert Group on Modelling Approaches. Both expert groups are co-chaired by the Chief Science Advisor and the deputy minister of Health Canada, Stephen Lucas. The groups include several members from the Expert Panel.

Updates from the WHO Coordination Call

  • Hospitals seem to be an important source of COVID-19 infection globally. As a result, WHO is considering a recommendation that all hospital staff and patients wear masks.
  • The US Centre for Disease Control and Prevention (CDC) will likely release recommendations for the public to protect themselves with homemade masks. UPDATE: The recommendation was released on April 3rd.

Blind Spots in Current COVID-19 Response

Testing

  • PCR testing is now conducted in Canada to confirm COVID-19 cases using risk criteria that are evolving; to-date more than 290,000 Canadians were tested for COVID-19. Current issues with PCR testing include supply of reagents and testing capacity.
  • The priority is to test healthcare workers and other frontline staff/essential service providers
  • Random sampling (at least 1,500 individuals) or broader general testing will provide a more comprehensive picture of who is infected with COVID-19 to better understand disease spread and enable more accurate modelling. As of April 2nd, the age distribution of COVID-19 patients in Canada does not align with countries where broader testing has been performed, suggesting we might not have the full picture.
  • Sequential or serial testing (i.e. when the same individual is tested multiple times, often from different parts of the respiratory tract) is advised to address false-negative test results (i.e. when individual is COVID-19-positive, but testing indicates that they are COVID-19-negative).

  • Serology testing is critical to identify the % of Canadians that have been exposed to COVID-19
  • When tests become available, the first priority should be healthcare workers and other frontline staff/essential service providers. Frontline workers with COVID-19 immunity could be working with less personal protective equipment (PPE).
  • Understanding the population-level immunity will also be important. If resources are limited, pooled testing can be explored (i.e. blood pulled from a number of individuals tested to identify population level).
  • Comprehensive testing of children (both serology and PCR testing) will clarify a current blind spot on whether children contract and transmit COVID-19.
  • Some serology tests have been developed outside Canada but their specificity and sensitivity are questionable. Of note, Gary Kobinger’s group at Laval University has apparently established a reliable serology lab test but would require scale up of antigen production.

Other

  • The data on compliance rates with government recommendations (segmented by the postal code, gender, age etc.) would be useful both for public messaging, predicting COVID-19 spread and for informing return to normal options. In other emergency situations, compliance rate varies from 50 to 80%.
  • Mental health consequences of COVID-19 need to be addressed. Given the knowledge as of April 2nd, research indicates that 28% of Canadians are highly anxious about COVID-19 and ~22% report being depressed. Appropriate services, including on line and tele services, would help Canadians deal with the mental health consequences of a public health and economic crisis of this magnitude (e.g. Ontario increased mental health support through expanding existing programs targeting children, adults and frontline healthcare workers).
  • Other blind spots/area in need of attention brought up by the expert panel include:
    • Linking epidemiological data with COVID-19 viral sequences.
    • Possible reinfection of individuals who have recovered from COVID-19.
    • Hospital-level capacity to deal with COVID-19 patients.

Recovery Strategy / Easing Containment Measures

What type of data should we be collecting to inform decision-making around easing containment measures?

  • Understanding which activities are safe and which are not; which measures have the greatest effect on limiting disease spread and hospitalization.
  • Getting granular epidemiological data on COVID-19 cases, ideally with the postal code resolution, would help better understand the situation and provide data for optimal modelling.
  • Once community-based transmission is under control in Canada, the danger of COVID-19 re-introduction is likely to come from global hotspots (i.e. international locations with high number of COVID-19 cases). Having information on international travel will be helpful to develop appropriate measures to mitigate the re-introduction of the virus.

 


 

 

Overview of Discussions

Meeting #8 of the CSA Expert Panel

Held by teleconference on April 7, 2020

 

The following discussion reflects evidence and scientific knowledge up to April 6th.

 


 

Summary

  • The objective of the meeting was to discuss the urgent challenges that research and clinical care communities currently face.
  • There is a need to address the availability and quality of epidemiological data to accurately model Canada’s COVID-19 outbreak
  • The shortage of personal protective equipment, respirators in particular, may require using expired and reprocessed respirators. Standardization of decontamination protocols would be of benefit.

Participating Experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital
  • Babak Pourbohloul PhD, University of British Columbia

 

Risk and Behavioural Sciences

 

  • Daniel Krewski PhD, University of Ottawa
  • Louise Lemyre PhD, University of Ottawa
  • Steven Taylor PhD, University of British Columbia

 

Biomedical and Clinical Sciences

 

  • Deborah Cook MD, McMaster University
  • Maziar Divangahi PhD, McGill University
  • Matthew Gilmour PhD, Public Health Agency of Canada
  • Gary Kobinger PhD, Université Laval
  • Joanne Langley MD, Dalhousie University
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Supriya Sharma MD, Health Canada
  • Caroline Quach MD, Université de Montréal
  • Cara Tannenbaum MD, Health Canada

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

Data Collection and Access

 

  • The epidemiologic data on the COVID-19 was published on canada.ca/COVID19 and StatCan. It was expressed that these data are not stratified enough to be informative for modellers. In particular, some of the data on COVID-19 cases is not broken down by province.
  • Some of that data that are needed for modelling are currently not being collected. Ideally, the number of daily positive and negative tests would be reported along with the reasons each individual was tested.
    • It was mentioned that some provinces do not have a mechanism to collect data on reasons for testing or information on the negative cases.
  • In particular, there needs to be better understanding of COVID-19 transmission and immunity among children in order to evaluate the risks and benefits of re-opening schools.
  • To gain a better understanding of immunity at the population level, a weekly data collection on seroprevalence pooled by age might be easier. Ideally, both serological and PCR data should be used to assess prevalence of COVID-19 infection in the population.

Serological Testing

  • Given the knowledge as of April 6, most of the current commercial serological testing kits apparently are not specific nor not sensitive enough.
  • The Public Health Agency of Canada’s National Microbiology Laboratory, along with a consortium of institutes across the country, are starting to systematically test different platforms and testing kits. The initial goal is to study seroprevalence, seroconversion, and immunity across select communities including healthcare workers.
  • Internationally, serology is a hot topic especially as a component of a containment exit strategy (e.g. the idea of an “immunity passport” explored by Germany and US).

Social Behaviour

  • Google has made publicly available sector-specific data on the impacts of physical distancing on mobility. These data could be used to aid public communications.
  • There are concerns that compliance is going to be an ongoing issue. Given the knowledge as of April 6, City of Ottawa issued 43 fines over past weekend for non-compliance with physical distancing measures.
  • One way to simultaneously study prevalence and behaviour could be to send out rapid home diagnostic kits (when those become available) with a companion behavioural survey.

Personal Protective Equipment (PPE)

PPE supply management

  • Hospitals are using a layered approach to PPE use at the frontlines: (1) Existing stock, (2) Pandemic stock sourced from other countries and donations, or repurposed from other sectors, (3) Expired stock, (4) Reprocessed stock.
  • Intubation and extubation are complex and high-risk processes. The anaesthesia community are repurposing other devices, like scuba masks, for full face coverage.

Reprocessing of PPE

  • Multiple publications (mostly in preprint form for now) propose protocols for PPE reprocessing. These have been shared with the expert panel.
  • PPE (except gloves) are often re-used during pandemics after decontamination. Reprocessing protocols that work include vaporized hydrogen peroxide and dry heat (60°C for 45min - not compatible with all respirator models).
  • Reprocessing of PPE is a complicated issue. Considerations include efficiency of pathogen removal, residual filtration efficacy and structural integrity.
  • Evidence suggests that reprocessing of N95 mask may be safe up to 5 times. There would need to be a clear and standardized labelling, which requires additional organization. Some expressed preference for one-individual one-mask approach.
  • Hospital’s capacity to reprocess single-use devices would depend on its size and access to necessary facilities, on-site processing might not be a possibility for small hospitals.
  • Health Canada commented PPE decontamination is a very active area of discussion among the federal departments (HC, Innovation Science and Economic Development (ISED), National Research Council (NRC), and Public Health Agency of Canada (PHAC)), who are examining methodologies, some of which already exist in hospitals for processing other devices.
    • They are pursuing two options: (1) deploying existing and new devices to hospitals to process PPE and (2) sending out PPE to be processed by third-party services.
    • The assumption is that there may be acceptability from the health worker community for re-processed PPE, given the extraordinary circumstances.
  • A Task force composed of a sub-group of this expert panel will meet to review the evidence on decontamination and reprocessing of N95 face masks and provide recommendations to the CSA.

 


 

 

Overview of Discussions

Meeting #9 of the CSA Expert Panel

Held by teleconference on April 14, 2020

 

The following discussion reflects evidence and scientific knowledge up to April 13th.

 


 

Summary

  • The objective of the meeting was to discuss COVID-19 research and surveillance efforts.
  • Population testing continues to be a challenge that should be addressed. Information from DNA testing as well as serology are essential elements for de-confinement strategies.
  • Understanding the immune response to COVID-19 infection is critical for successful vaccine strategies
  • Canada should be planning for vaccine procurement, mass manufacturing and distribution of more than one vaccine candidate at earlier stages of development than traditionally done.
  • A more coordinated scientific and medical advice and oversight for COVID-19 clinical studies (therapeutics and vaccines) should be explored and linked with procurement processes.

Participating Experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital

 

Risk and Behavioural Sciences

 

  • Louise Lemyre PhD, University of Ottawa
  • Daniel Krewski PhD, University of Ottawa
  • Steven Taylor PhD, University of British Columbia

 

Biomedical and Clinical Sciences

 

  • Deborah Cook MD, McMaster University
  • Maziar Divangahi PhD, McGill University
  • Matthew Gilmour PhD, Public Health Agency of Canada
  • Gary Kobinger PhD, Université Laval
  • Joanne Langley MD, Dalhousie University
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Supriya Sharma MD, Health Canada

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

Update from the Task Force on N95 Face Masks Reprocessing

 

  • After the last meeting, the CSA struck a task force composed of several expert panel members to provide advice on the N95 face mask reprocessing.
  • The CSA thanked the task force for their high quality, evidence-based report which was shared with both Health Canada and Innovation Science and Economic Development.

Public Perception and Behaviour

  • An ongoing study (currently under review) surveyed ~7,000 nationally representative adults in Canada and US on their perceptions of and reactions to COVID-19
    • Respondents were divided into 3 clinically relevant groups: under-responsive (28%), normative (46%), high anxiety (26%).
    • The high anxiety group is associated with depression, COVID-related nightmares, as well as behaviours like frequent checking of COVID-19 news and panic buying.
    • Respondents in the under-responsive group believe themselves to be impervious to infection.
    • 22% of the under-responsive group, and 17% of other groups, indicate they would refuse a SARS-CoV-2 vaccine if it becomes available.
    • A second wave of the study will begin soon to investigate whether these groups are stable over time.
  • As part of the recovery strategy, there should be targeted messaging for groups who are more likely to be going back to work.
  • It may be pertinent to consider guidelines on age restrictions for a back-to-work plan — an agenda item for the next meeting.

Data and Modelling

  • Public Health Agency of Canada (PHAC) has released some exploratory modeling results, supported by modelling from external sources. These broadly agree with BC’s models.
  • The data that PHAC and Statistics Canada have made publicly available are pooled data and not useful for modelling (e.g. data is not stratified by province). Discussions at the modelling expert group are tackling this issue.
  • To get a clear understanding of COVID-19 case count vs. true prevalence, data on time to hospitalization, time to death, indication for tests, timing of tests, incubation periods are needed. These data are currently not being collected or collated.

Capacity for COVID-19 Testing

  • There is increasing interest in serological testing to detect antibodies as a readout for immunity against COVID-19 and to get better information on disease prevalence.
  • Serology testing is not in lieu of PCR testing as they provide different and complementary information.
  • Ramping up PCR testing remains important.
  • The Public Health Agency of Canada’s National Microbiology Laboratory (NML) is starting to evaluate serology kits for reliability. They reported that the specificities of several tests are very good, though sensitivity is sometimes low (this could be due to the timing of serum collection). The rapid diagnostic tests and lateral flow assays also look promising.
  • Public Health Labs are under pressure to test (using PCR testing) high-risk populations. This, combined with reagent shortages, can mean that research-oriented specimens are de-prioritized (e.g. longitudinal testing to inform prevalence or testing of pediatric population).
  • A shortage of the plastic materials needed to make the 96-well plates used in testing is apparently creating another bottleneck.
  • Health Canada (HC) indicated there are multiple approaches being taken to expand testing capacity:
    • To address the swab shortage, HC is looking at protocols to decontaminate swabs as well as working with companies to 3D print swabs.
    • To address the reagent shortage, the NML is working on homebrew PCR testing reagents. There is also a company in Atlantic Canada working on producing PCR testing reagents.
    • To address the needs of rural and remote communities, HC has approved a rapid diagnostic test by Spartan Bioscience.

Vaccines and Clinical Trials

  • The importance of a coordinated approach aimed at accelerating promising vaccines to mass production for Canadians was emphasized; this would include a plan for vaccine procurement, mass manufacturing and distribution.
  • It is important to test different vaccine strategies, engage with different companies, and ideally identify more than one successful candidate at early stage for mass production. It is also possible that different vaccines may be needed for different populations (e.g. older adults).
  • China will soon release their Phase 2 clinical trials data on vaccine candidates and is moving quickly to have a vaccine available for its population.
  • Caution is needed around selecting promising vaccines until we have a better understanding of the human immune response to the COVID-19 virus (SARS-CoV-2).
  • HC noted it is taking part in discussions on the requirements for vaccine authorization with the International Coalition of Medicines Regulatory Authorities (ICMRA), with participation from the World Health Organization.
    • HC is talking to companies about plans for clinical trials and vaccine development in Canada.
    • The Government of Canada is funding infrastructure across the country to enable domestic production of vaccines.
    • HC is facilitating the procurement process. Some companies have indicated a preference for a nationalized approach to procurement (rather than individually dealing with provinces and territories).
    • HC is tracking global clinical trials and Canada’s participation in the Solidarity trials.
    • HC is also tracking ongoing and planned clinical trials for COVID-19 therapeutics in Canada. Further conversations on access to therapies and mitigating shortages are taking place at the pan-Canadian Pharmaceutical Alliance (pCPA) table.
    • PHAC is convening a clinical issues group to advise on clinical trials.

Research Coordination and Pandemic Preparedness

  • In France, President Macron has requested the creation of a high-level committee reporting jointly to the Minister of Health and Minister of Research, Innovation and Higher Education – link in French. It provides coordinated practical advice on diagnostics, clinical trials and vaccine development.
    • This is potentially a good model for Canada.

 


 

 

Overview of Discussions

Meeting #10 of the CSA Expert Panel

Held by teleconference on April 17, 2020

 

The following discussion reflects evidence and scientific knowledge up to April 16th.

 


 

Summary

  • The objective of the meeting was to discuss key considerations for easing containment measures in Canada and a long-term national strategy for infectious disease research and surveillance.
  • Canada’s recovery plan should take into consideration health systems capacities, enhanced testing and monitoring as well as specific guidance on public hygiene and face coverings (masks) for the general population. Phased deconfinement, region and sector specific approaches as well as impact on vulnerable populations should be considered.

Participating Experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University

 

Risk and Behavioural Sciences

 

  • Louise Lemyre PhD, University of Ottawa
  • Daniel Krewski PhD, University of Ottawa

 

Biomedical and Clinical Sciences

 

  • Maziar Divangahi PhD, McGill University
  • Matthew Gilmour PhD, Public Health Agency of Canada
  • Gary Kobinger PhD, Université Laval
  • Joanne Langley MD, Dalhousie University
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Supriya Sharma MD, Health Canada

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

Considerations for Recovery Phase / Easing Containment Measures

 

  • The PM has asked for input to inform easing of containment measures in Canada

Social and behavioural perspective

  • The Psychosocial annex of the Canadian Pandemic Influenza Preparedness planning guide provides guidance on issues such as the thresholds for distress, violence, and grief, and the resources needed to bring people safely back to work.
  • Understanding the workers perspective and preoccupation for their return to work is important and will be sector specific in terms of protective measures and support to maintain safe environments.
  • Discussions and coordination with unions may be beneficial for phased return to work strategies.

Sector-specific guidelines

  • Canadians have guidance on how to stay home and to physically distance. Clear guidance will be required for the recovery phase / ease of containment measures. Before relaxing existing measures, the public needs guidance on activities and locations such as places of business, transportation, and healthcare.
  • Guidelines that are sector-specific would be most beneficial.

COVID-19 Testing

  • Canada does not yet have the required level of COVID-19 testing in order to quickly monitor effectiveness/safety of public health measures. Epidemiologic data at the population level such as how many are infected and how many have been infected or who is at risk remain uninformative.
  • There is a need to be better understand how COVID-19 affects children because the return to normalcy depends on the reopening of schools and daycares.
    • Recruiting non-clinical laboratories that have the expertise and resources to carry out the PCR tests from research and clinical samples is a potential way to substantially expand Canada’s testing capacity. There is no complicated certification process, laboratories need only to complete a proficiency panel (to show that their testing is of sufficient quality). Proficiency panels are issued by provincial health authorities.

Masks

  • There is a need for a clear recommendation by federal and provincial chief health officers regarding the use of home-made masks during the recovery phase, either for general use in public or use in confined spaces where physical distancing is not possible (eg. public transit, shopping centres, etc.).
  • Children are unable to wear masks consistently and safely, so the potential for mixed-messaging is high. Compliance may be higher when children are accompanied by adults (eg. public transit, shopping etc.)
  • If masks are recommended, there needs to be guidance on the appropriate types of materials, donning and doffing procedures and the importance of maintaining the current safety measures such as regular handwashing, coughing etiquette, etc.
  • If general mask use is recommended for return-to-work, governments/employers should consider providing face masks to individuals who are not able to make their own.
  • There needs to be clear articulation to the public that masks do not eliminate the risk of infection but help reduce the spread.

Administrative matters

  • Workplaces should consider adopting various requirements to report symptoms and illness, address issues related to leave without medical diagnosis, as well as insurance and liabilities. Especially if testing not readily available.
  • Return-to-work strategy may happen in a phased approach, asking low-risk individuals to return to work first and higher-risk individuals (eg. older people and individuals with chronic diseases) to stay home.

Ideas for a National Strategy for Infectious Disease Research, Development and Preparedness

  • To maintain focus on infectious disease research and development and ensure better preparedness and coordination for future epidemic(s), the expert panel has discussed an idea of a national strategy for infectious disease research, development and preparedness.

Existing models to emulate

  • A relevant US model is the Centres of Excellence for Influenza Research and Surveillance (CEIRS):
    • NIH-funded decentralized network, with different centres holding different expertise.
    • This network has open sharing of reagents and protocols, eliminating the need for material transfer agreements (MTAs) and data sharing agreements for every collaboration (a challenge Canadian researchers have faced during COVID-19).
    • Ongoing relationships make it easy to pivot to new research targets.
    • The network increases capacity and decreases redundancy in instrumentation and infrastructure and provides ample shared services.
    • A great way to galvanize highly qualified personnel (HQP) training.
  • Canada’s NCE on bovine spongiform encephalopathy (BSE) is potentially a good model. It had basic and applied research including in social sciences, international outreach, policy components, partnerships, etc. A paper on this NCE will be shared with the group.

Funding challenges

  • Some expert panel members expressed perspective that current research funding in Canada for COVID-19 is suboptimal. Multiple funding calls, each with a different format and low success rate, are leading to application fatigue among researchers while increasing administrative burden.
  • A living document that tracks evidence and expertise (e.g. the UK’s EPPICentre) can highlight which areas have received significant funding and those not being funded.

Science Communication

  • The expert panel has noted the negativity and criticism among the public about the amount of PCR testing carried out. There is also a lack of understanding why serological testing development is taking so long.
  • Clear, plain language public messaging around the need for both PCR (DNA-based) and serological testing should to be considered.

 


 

 

Overview of Discussions

Meeting #11 of the CSA Expert Panel

Held by teleconference on April 21, 2020

 

The following discussion reflects evidence and scientific knowledge up to April 20th.

 


 

Summary

  • The objective of the meeting was to discuss key considerations for Canada’s easing of containment measures.
  • The panel agrees on three key criteria before considering relaxation of measures: (1) controlling COVID-19 transmission, (2) sufficient health systems capacity and (3) sufficient testing, contact tracing and surveillance capacity.
  • The ease of containment measures should be done gradually with sufficient time to measure impact, and clearly articulated guidelines, sustained efforts to prevent infection spread, and clearly defined criteria for when return to stricter measures might be necessary.

Participating Experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital

 

Risk and Behavioural Sciences

 

  • Louise Lemyre PhD, University of Ottawa
  • Daniel Krewski PhD, University of Ottawa
  • Steven Taylor PhD, University of British Columbia

 

Biomedical and Clinical Sciences

 

  • Deborah Cook MD, McMaster University
  • Maziar Divangahi PhD, McGill University
  • Matthew Gilmour PhD, Public Health Agency of Canada
  • Joanne Langley MD, Dalhousie University
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Caroline Quach MD, Université de Montréal
  • Supriya Sharma MD, Health Canada

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

Feedback on Draft Recommendations for Easing Containment Measures

 

  • Draft recommendations for easing containment measures were circulated for the expert panel’s review and feedback.
  • Recommendations aim to contain both high-level guidelines, as well as specific indicators where needed.
  • It was agreed that the underlying principles and recommendations are sound. Members raised the need for more specific indicators for maximal practical help.

Currently missing from the guidance document:

  • A coherent plan for how data (e.g. contact tracing, population level testing) will be synthesized.
    • The expert group on modelling has provided recommendations on data needs.
  • Data to support opening schools and day care are still lacking, because we currently do not have a good understanding of SARS-CoV-2 transmission and immunity among children.
    • Pilot openings in areas of low case burden, accompanied by extensive testing, can be considered as a potential approach.

On controlling COVID-19 transmission:

  • Steps need to be taken to identify and protect high-risk workers in addition to healthcare workers (e.g. drivers, cashiers, daycare workers).
  • “Decreased transmission” and “stabilized transmission” are two different concepts. They need to be separated and defined.
  • Section on opening borders needs to be further elaborated.

On ensuring sufficient health system capacity:

  • The key is to maintain COVID-19 cases far enough below the healthcare capacity such that the system can allow for an increase in cases once public health measures are eased or lifted.
  • Recommended timeframes should take into consideration the reality that intensive care unit (ICU) capacity issues trail new cases by around 3 weeks.

On ensuring sufficient testing and monitoring capacities:

  • A better understanding of viral prevalence among different demographics (e.g. rural, urban, age groups), as well as the proportion of asymptomatic cases, is critical.
  • Bluetooth-based apps for contact tracing, if implemented, should be used with care. In addition to privacy concerns, Bluetooth may not capture accurate information about proximity to potential source of infection.
  • Serological testing may not be indicative of immunity and basic immunology studies are still needed. Caution should be exercised in public communications.

COVID-19 Testing

  • The Public Health Agency of Canada’s National Microbiology Laboratory (NML) provided an update on diagnostic testing, especially, point of care and lateral flow tests being considered.
  • There continues to be a need for reliable data on infection prevalence in Canada.

COVID-19 Clinical Trials Coordination

  • Clinical trials coordination in Canada is desirable to avoid small inconclusive studies.
  • For therapeutic clinical trials, with the exception of critical care trials that are well-organized, there is no pre-existing structure to support collaboration. The increasing number of trials risk being underpowered because of limited patients and funding.
    • There needs to be a sustained national effort to manage this process but it is unclear where this should happen and who should lead.

Vaccines

  • Government’s plan to secure promising vaccine candidates for Canadians was raised.

 


 

 

Overview of Discussions

Meeting #12 of the CSA Expert Panel

Held by teleconference on April 24, 2020

 

The following discussion reflects evidence and scientific knowledge up to April 23rd.

 


 

Summary

  • The objective of the meeting was to review the revised recommendations for easing containment measures. The expert panel endorsed the draft document.
  • The expert panel also discussed existing gaps in COVID-19 research and clinical trial coordination. Canada would benefit from a coherent overarching research strategy that integrates all the different elements of population, clinical, and basic COVID-19 science.

Participating Experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University

 

Risk and Behavioural Sciences

 

  • Louise Lemyre PhD, University of Ottawa
  • Daniel Krewski PhD, University of Ottawa
  • Steven Taylor PhD, University of British Columbia

 

Biomedical and Clinical Sciences

 

  • Deborah Cook MD, McMaster University
  • Maziar Divangahi PhD, McGill University
  • Matthew Gilmour PhD, Public Health Agency of Canada
  • Joanne Langley MD, Dalhousie University
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Supriya Sharma MD, Health Canada

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

Feedback on Draft Recommendations for Canada’s COVID-19 Recovery Phase

 

  • Revised draft recommendations for easing containment measures were circulated and endorsed.
  • Health Canada commented that the recommendations of the CSA’s Expert Panel for easing containment measures are very timely.
  • A technical advisory committee at PHAC has conducted reviews on what is known about COVID-19 in children. This was circulated to the expert panel.

New Federal Funding for COVID-19 Research & Development

  • The CSA asked for feedback on whether there are any gaps in the newly announced federal funding for COVID-19, which includes:
    • Pan-Canadian Serology Initiative - $300 million to support biobanking and basic research into immunology and virology.
    • Canadian COVID-19 Genomics Network (CanCOGeN) - $40 million to support viral and host genomic sequencing.
    • $633.3 million overall to support pre-clinical testing and clinical trials for vaccines through both public and private sectors.
    • $29 million to scale up NRC facilities to ensure capacity for vaccine production.
    • $10 million to establish clusters of modelling and data monitoring capacity in Canada
    • $114.9 million to support more research projects through CIHR.
  • New funding for research is welcomed news. However, an overarching strategy to guide COVID-19 science funding is desirable.
  • Clinical trial coordination:
    • Canadian Treatments for COVID-19 (CATCO) is supported by Canadian Institutes for Health Research, as well as the Canadian Critical Care Trials Group and the Association of Medical Microbiology and Infectious Disease Canada to do Solidarity trails in Canada. Sunnybrook and UBC are the first sites to enroll patients, CATCO is expecting up to 20 hospitals to participate. They are currently engaging boots on the ground to liaise with clinicians treating COVID-19 patients to recruit them into trials.
    • There are efforts to standardize consent forms, contracts, ethics approvals and to abbreviate case report forms through the National Methods Centre. This is desirable on a national level.
    • The best coordination to date happened through the Canadian Critical Care Clinical Trials Group (CCCTG), but these efforts are led by individual ICU physicians and not through a national framework. The reason for these collaborative efforts are pre-existing relationships among physicians (CCTG has existed since 1980). This is a model to emulate.
    • For example, patients recruited into clinical trials could be enrolled automatically in serology initiatives. Currently, there is nothing systematic in place to facilitate this.
    • There is also a need for coordination among the vaccine researchers in Canada. Given the expert panel knowledge as of April 23, high-level meetings have not taken place to coordinate vaccine efforts.
  • COVID-19 Diagnostic/Testing Strategy
    • The overarching strategy for testing, which would include PCR testing, viral prevalence testing (potentially through pooled testing) and serology initiative would be of benefit.
    • Currently, there is a paucity of Canada-specific data on COVID-19 prevalence. Prevalence testing is important and has to feed into serological data.
    • The objectives of the new COVID-19 Immunity Task Force could be integrated within the context of the entire diagnostic strategy and the available tools, not only immunity focused. There needs to be an overall understanding of the natural course of the immune response in infected patients, which is essential for vaccination strategies.
  • There is a benefit to networked approach to COVID-19. The notion of a network requires explicit harmonization, common protocols and data sharing.
  • The CSA proposed to discuss the concept of coordination, both in the short-term (starting with coordinating clinical trails, PCR testing, serology and prevalence testing) and in the long-term coordination of efforts. These would not only be high-level principles, but practical actions. Ultimately, these could be elements of a potential National Strategy on Infectious Disease Research, Development, and Preparedness.
    • Who are the appropriate people to bring this together and provide leadership?
    • What does success in coordination look like? How do we collect the data we need in a coordinated and integrated way?
    • What kind of long-term planning is needed?

 


 

 

Overview of Discussions

Meeting #13 of the CSA Expert Panel

Held by teleconference on May 1, 2020

 

The following discussion reflects evidence and scientific knowledge up to April 30th.

 


 

Summary

  • The objective of the meeting was to continue discussions on a coordination strategy for COVID-19 science and research activities.
  • Canada’s COVID-19 science and research activities would benefit from coordination through existing networks and natural points of connectivity (e.g. along the biobanking and data collection pipelines).
  • Key areas of COVID-19 data monitoring that need support include data collection and management, and integration of modellers with public health and laboratories.

Participating Experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital

 

Risk and Behavioural Sciences

 

  • Daniel Krewski PhD, University of Ottawa
  • Louise Lemyre PhD, University of Ottawa
  • Steven Taylor PhD, University of British Columbia

 

Biomedical and Clinical Sciences

 

  • Maziar Divangahi PhD, McGill University
  • Gary Kobinger PhD, Université Laval
  • Joanne Langley MD, Dalhousie University
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Caroline Quach MD, Université de Montréal
  • Supriya Sharma MD, Health Canada

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

The COVID-19 Immunity Task Force

 

  • The CSA provided an overview and asked for feedback:
    • The new COVID-19 Immunity Task Force includes several members of the expert panel. The complete list of membership can be accessed here.
    • The first meeting took place on Tuesday, April 28. The objective was to identify priorities around who will be tested and how.
    • Four subgroups were formed: (1) Testing; (2) Cohorts; (3) Community testing; and (4) Immunology.
    • Members of the COVID-19 Immunity Task Force are encouraged to consult broadly with external experts.
  • The expert panel stressed the importance of involving biostatisticians in the work of the taskforce from the start to ensure high-quality informative studies. This is a major concern given the recent release of high profile but poor quality seroprevalence studies by other countries. The biostatistician expertise could be represented at the taskforce or secretarial level.

Short-Term Coordination of COVID-19 Science and Research Activities

  • The CSA posed three questions to the expert panel about what is needed in the short-term for coordination of Canada’s COVID-19 science and research activities.

Question 1: How to practically coordinate diagnostic, serology and prevalence testing, recognizing existing systems and organizations across Canada? What would be a good way to bring this together?

Updates on testing

  • There are currently two relevant documents being developed on testing by the National Microbiology Laboratory (NML): one on a COVID-19 testing strategy framework and another on laboratory testing guidelines. These will include considerations for asymptomatic testing in specific settings to support the recovery process.
  • Internationally, PCR is still the favoured test of active infection.
  • Testing objectives have evolved as the epidemic in Canada has progressed:
    • Initially, testing was for detecting cases in order to treat, isolate, and contact trace.
    • More recently, there have been more proactive interval testing in light of the crises at long-term care homes.
    • Now, with accumulating evidence on asymptomatic patients, there is a role for random testing to detect undiagnosed cases among the population. This baseline understanding of prevalence is needed before broad relaxation of public health measures.
    • To do longitudinal studies, there would need to be agreements with and among regional public health laboratories because they are doing the testing.
  • Findings from serology testing could be useful for guiding return-to-work policies. Many companies are asking if they should be testing employees (especially if they are from vulnerable populations).
  • Including socio-behavioural data alongside the testing is a consideration. This could include inviting Canadians undergoing COVID-19 testing for online follow-up with regards to demographics, behaviours, perception, wellbeing and other social considerations, thereby creating a registry of potential volunteers across Canada for future surveys or clinical research.

Coordination of testing efforts through networks

  • Prompted by the PCR reagent shortage early in the epidemic, all public health laboratories sent out calls to the research community for reagents through universities, professional organizations, clinical microbiology laboratories, and national associations. Could there be a way to harness the network created through this call for coordination of testing?
  • The biobanking process is another opportunity to create coordination.
  • The experts emphasized a need to have more clarity on how to collect high-quality biologic samples, how and where to store them for host-virus sequencing and for serology. The management and finance of the biobanking infrastructure was also discussed.
  • To encourage open sharing of samples, one approach is to “follow the sample” and engage relevant stakeholders in the process. It is also important that researchers have access to the data generated.
  • Biobanking initiatives are currently present in BC, ON and QC; they are regional in nature. It would make sense to have provincial/regional coordination mechanisms and then a network to bring together all efforts across the country. This could be done through regional genome centres.

Question 2: How do we best prepare to have clinical coordination for COVID-19 research, including sampling for serology, and clinical cohorts for vaccine and therapeutic trials?

  • A clear understanding of what is underway or planned in Canada is needed.
  • Currently, information on ongoing trials is available in the following places:
    • Health Canada maintains a list of all approved clinical trials.
    • Observational trials or trials involving approved products that do not require Health Canada approval can be found at clinicaltrials.gov.
    • The World Health Organization receives data once a week from clinical trials, these are broader spectrum.
    • The Canadian Institute of Health Research has funded a number of trials in Canada.
  • The newly set up CanCOVID platformFootnote 3 could be a place for coordination; however, clinical trial researchers are currently not very active on the platform possibly due to clinical demands during the pandemic.

Question 3: Who would be the group or people to establish a virtual national methods centre to harmonize contracts, ethics approvals (REB) and other key elements?

  • The experts noted that contracting for clinical trials is mostly local. Many, though not all, trials are sponsored by companies, in which case they do their own contracts.
  • REBs have been responding very quickly, with fast turn-around on approvals.
  • In France, a high-level group, supported by the government, was established to coordinate therapeutic and vaccine trials and ensure end-to-end harmonization. Could Canada benefit from a body like this to ensure viable options for scale-up and production?
  • The expert panel was informed by one of its members of an upcoming meeting to look at coordinating vaccine candidates in Canada; participants include the Canadian Immunization Research Network (CIRN), the Canadian Association for Immunization Research and Evaluation (CAIRE), Health Canada and the Public Health Agency of Canada.
    • It was suggested that discussions may include players from Innovation, Science and Economic Development, given their link to the industry and supply chains, which will need to be considered.

Data and Modelling

  • The CSA asked the expert panel for feedback on the newly announced funding for data monitoring.
    • $10 million for a Canadian data monitoring initiative so we can coordinate and share pandemic-related data across the country to enhance Canada’s response to COVID-19 (PM Announcement, April 23, 2020).
  • It was noted that modellers continue to find it challenging to access relevant COVID-19 data from Statistics Canada or the Public Health Agency of Canada.
  • The experts identified data gathering, management, and stewardship as key areas of data monitoring that need funding support.
  • In order to obtain the right kind of data, one could “follow the sample” to identify and fix any “broken links” along the data chain. There is a need for integration of modelling groups with public health agencies and laboratories so that they can access the right data.

 


 

 

Overview of Discussions

Meeting #14 of the CSA Expert Panel

Held by teleconference on May 8, 2020

 

The following discussion reflects evidence and scientific knowledge up to May 7th.

 


 

Summary

  • The objective of the meeting was to discuss COVID-19 testing and the practical and ethical considerations for contact-tracing apps. Further, the expert panel was asked for suggestions on the key data to be collected for the COVID-19 Immunity Task Force’s serosurveys.
  • Pressing issues regarding testing include a potential lack of storage capacity for biobanking, and the need to determine how much testing would be needed to safely relax containment measures.

Participating Experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital

 

Risk and Behavioural Sciences

 

  • Daniel Krewski PhD, University of Ottawa
  • Louise Lemyre PhD, University of Ottawa

 

Biomedical and Clinical Sciences

 

  • Deborah Cook MD, McMaster University
  • Maziar Divangahi PhD, McGill University
  • Gary Kobinger PhD, Université Laval
  • Joanne Langley MD, Dalhousie University
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Supriya Sharma MD, Health Canada

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

Suggestions on Data Elements to be Collected by COVID-19 Immunity Task Force

 

  • The population survey and longitudinal cohorts working group of the COVID-19 Immunity Task Force are in the process of outlining the core data elements to be collected. The CSA asked the expert panel members for their suggestions.
  • The CSA shared that the initiative will be rolled out with multiple arms and sites. Research hospitals and academic centres, led by research and clinician scientists, will be funded to collect a standardized set of data. Furthermore, discussions with Genome Canada are ongoing to coordinate collection of similar data to maximize use of each sample, and capture as many patients as possible for serology.
  • The cohort study will include a prospective, longitudinal element, which will require periodic re-testing of individuals to assess the possibility of reinfection, taking into consideration other health issues as well.
  • The expert panel made the following suggestions:
    • When collecting information about risk of exposure, it would be helpful to include considerations for occupations that are not healthcare or essential services (e.g. meat packing plants, prisons).
    • Timing of exposure and timing of symptom onset, if known, would be important information to gather.
    • Other useful information includes geographical location of individuals – urban vs rural, apartment building vs detached home, etc.
    • Contact patterns – on a typical day, who are the individuals contacts? How old are they?
    • In addition to PCR-confirmed COVID-19 diagnoses, it could be useful to include information about whether individuals suspected they had COVID-19 in the absence of PCR test confirmation.
    • Include behavioral questions– e.g. How many hours per day were you outside your home?

Considerations for COVID-19 Testing

Biobanking

  • Biobanking efforts are dependent on sample storage capacity. The experts expressed concern about a potential risk of samples being discarded due to lack of storage space. Containment level 2 facilities are sufficiently equipped and could be engaged more for COVID-19 testing, diagnosis, and sample storage.

Level of testing needed

  • The level of testing needed depends on the purpose of testing. For example, if testing is to be used to replace physical distancing, then an order of magnitude increase in testing (compared to current levels of testing) may be needed. Models estimate that 3-4% of prevalent cases per day would need to be identified through testing and tracing.
  • We have some of the data needed to make informed estimates about how much testing is needed in a back-to-work scenario. Additional information would be needed about contact patterns and how they affect community transmission.

Targeted testing for vulnerable populations

  • Regular testing for vulnerable populations, such as residents and workers in long-term care homes, are key considerations.
  • At what intervals should regular testing be done? There is no clear answer since it depends on the setting. Existing knowledge suggests weekly or shorter intervals for certain high-risk environemnts. A balance is needed between protecting vulnerable populations and the discomfort of testing procedures (nasopharyngeal swabs) is suggested.

Opportunities and options in testing

  • The World Health Organization is evaluating ways to shorten the mandatory 14-day isolation period, e.g. 10+3: 10 days after onset of symptoms or 3 days after resolution of symptoms.
  • Serosurveys are now being conducted to follow antibody-positive patients over months to assess whether they can be re-infected, and if yes, assess the severity of the second illness.
  • A nasopharyngeal wash seems to produce specimen with sensitivity as high as a nasopharyngeal swab. This could be useful because a wash is more comfortable for some, compared to a swab.
  • Some places, like the Centres for Disease Control and Prevention, are moving toward patient-collected nasal swabs, which saves on personal protective equipment.
  • For influenza, there is not much difference between nasal and nasopharyngeal swabs, even at different stages of illness. This may be the case for SARS-CoV-2 as well, but as of May 7, this has not been tested rigorously.
  • Saliva is another potential alternative to nasopharyngeal swabs, and can also be used to test for antibodies. The disadvantage is that saliva is difficult to store, as it contains enzymes that degrade the virus. Researchers are currently exploring ways to stably store saliva samples.

Considerations for Use of Contact/Proximity-Tracing Apps for COVID-19

  • The CSA has asked Canadian Institutes for Advanced Research to produce a report on “Society, Technology, and Ethics in a Pandemic,” with a focus on contact/proximity-tracing apps.
  • The CSA asked the expert panel for feedback on this topic. The expert panel highlighted points of consideration regarding the use of COVID-19 contact/proximity-tracing apps.

Questions raised

  • Will contact-tracing technologies be useful in long-term care homes and hospital wards, and among the 70+ year old population, where the risk of infection and severe COVID-19 are highest?
  • Are contact-tracing apps effective in public transportation scenarios?
  • Will all apps and other contact-tracing technologies in Canada be required to be available in both official languages?
  • How can data safety and privacy be guaranteed?
  • How to minimize false-positives and negatives of contact-tracing apps given phones and their sensors are imperfect proxies for exposure, e.g. false positives through walls or if phone is not with its owner?
  • How to address disproportionate impact on lower income and marginalized communities, who are more likely to live in densely populated spaces, possibly resulting in higher false positive rates.
  • If apps rely on information from provincial-level testing, then multiple levels of coordination may be required. How will this be addressed?

 


 

 

Overview of Discussions

Meeting #15 of the CSA Expert Panel

Held by teleconference on May 15, 2020

 

The following discussion reflects evidence and scientific knowledge up to May 14th.

 


 

Summary

  • The objective of the meeting was to share the latest scientific updates on COVID-19 in children and the risk factors for severe outcome from COVID-19.
  • Available data makes it difficult to determine if children are significant transmitters of COVID-19. The increase in cases of Kawasaki syndrome in children is a potential concern for SARS-CoV-2 vaccination.
  • Evidence gathering for COVID-19 risk factors is still ongoing, providing an opportunity to coordinate research collaborations and data sharing to generate large common datasets.

Participating Experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital

 

Risk and Behavioural Sciences

 

  • Daniel Krewski PhD, University of Ottawa
  • Louise Lemyre PhD, University of Ottawa

 

Biomedical and Clinical Sciences

 

  • Deborah Cook MD, McMaster University
  • Maziar Divangahi PhD, McGill University
  • Gary Kobinger PhD, Université Laval
  • Joanne Langley MD, Dalhousie University
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Caroline Quach MD, Université de Montréal
  • Supriya Sharma MD, Health Canada
  • Cara Tannenbaum MD, Université de Montréal, Health Canada Departmental Science Advisor

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

COVID-19 in Children

 

  • The expert panel identified key information needed to help guide the safe reopening of schools and preparation for a potential second wave of infection.
  • The suggestion was made to form a Task Force on COVID-19 in Children.

Directionality of COVID-19 transmission in children

  • Given the knowledge as of May 14, the key question of how likely it is for children to pass infection to adults is difficult to answer for a variety of reasons, including the fact that children have been infected through clusters of COVID-19 outbreak, but are rarely the index cases, and the fact that school closures decrease contacts and cases.
  • Montreal is recruiting randomly, as well as through all hospital admissions, for serosurveys and nasal swabs to study COVID-19 incidence in children and their parents, but are unable to determine directionality (whether the parent infected the child, or vice versa).
  • A study (Danis et al., Clinical Infectious Diseases) where a child with symptomatic COVID-19 did not transmit the infection despite over 170 contacts with adults suggests that children are less infectious.
  • It would be useful to examine data from Sweden, where schools were never closed, to see if children have been index cases in clusters or outbreaks.
  • Another potential source of data is religious communities with previous outbreaks at large gatherings, where children could have been part of the chain of infection.

COVID-19-linked Kawasaki syndrome in children

  • The KawasakiFootnote 4 cases observed in children (France, Canada, and other counties) could also have implications for young adults, as it may be due to pre-exposure to SARS-CoV-2. Epidemiological data are needed, including the exposure history of the children.
    • The World Health Organization is trying to make Kawasaki a reportable syndrome to better capture whether cases are truly increasing and at what rate.
    • Le Centre Hospitalier Universitaire Sainte-Justine in Montreal is currently recruiting a cohort for a study, after seeing an increase in incidence of Kawasaki cases. It would be possible to survey the families about exposure and pre-exposure to COVID-19 in this context.
  • Current efforts include the Canadian Pediatric Surveillance program, which is conducting surveys through automated emails to all pediatricians to identify cases of Kawasaki, and the Canadian Nosocomial Surveillance program, which is also conducting weekly surveillance on hospital admissions by age.

Risk Factors for COVID-19

Risk factors

  • Researchers are continuing to gather data on risk factors through observational studies.
  • The risk factors for COVID-19 onset and progression to severe illness are different.
    • For onset, risk factors include occupation, e.g. working in a healthcare or long-term care settings. Exposure risk will also change as physical distancing measures are lifted.
    • For progression to severe illness, the Centres for Disease Control and Prevention has a list of probable risk factors that include persons aged over 65, severe lung or heart disease, diabetes, and a compromised immune system.

Data collection and analysis

  • Demographic data are needed for both positive and negative cases. The negative cases serve as control data, which are needed to make determinations about risk factors.
  • It was pointed out that Thrive Health, the company that created the Canada COVID-19 Support App, has had difficulties in acquiring approval to collect demographic data along with user-reported symptom data. The app has over 200,000 user responses and over 50,000 users responding with symptoms, and could be an important source of information on demographic-based risk factors.

 


 

 

Overview of Discussions

Meeting #16 of the CSA Expert Panel

Held by teleconference on May 19, 2020

 

The following discussion reflects evidence and scientific knowledge up to May 18th.

 


 

Summary

  • The objective of the meeting was to seek the expert panel’s feedback on the updated National Laboratory Testing Indication Guidance for COVID-19 from the Public Health Agency of Canada.
  • Testing of asymptomatic individuals in settings with high pre-test probability should be considered in order to control current outbreaks or prevent future outbreaks.

Participating Experts:

  • Mona Nemer PhD, Chief Science Advisor of Canada (chair)

 

Disease Modelling

 

  • Caroline Colijn PhD, Simon Fraser University
  • Kamran Khan MD, St Michael’s Hospital

 

Risk and Behavioural Sciences

 

  • Daniel Krewski PhD, University of Ottawa
  • Louise Lemyre PhD, University of Ottawa
  • Steven Taylor PhD, University of British Columbia

 

Biomedical and Clinical Sciences

 

  • Deborah Cook MD, McMaster University
  • Maziar Divangahi PhD, McGill University
  • Gary Kobinger PhD, Université Laval
  • Joanne Langley MD, Dalhousie University
  • Allison McGeer MD, Mount Sinai Hospital
  • Samira Mubareka MD, Sunnybrook Research Institute
  • Guillaume Poliquin MD PhD, Public Health Agency of Canada
  • Caroline Quach MD, Université de Montréal
  • Supriya Sharma MD, Health Canada
  • Cara Tannenbaum MD, Université de Montréal, Health Canada Departmental Science Advisor

 

Other

 

  • Masha Cemma PhD, Office of the Chief Science Advisor (support)
  • George Enei P.Eng, Office of the Chief Science Advisor (support)
  • Vanessa Sung PhD, Office of the Chief Science Advisor (support)

 

National Laboratory Testing Indication Guidance for COVID-19

 

  • The expert panel was provided a draft copy of the updated Public Health Agency of Canada (PHAC) guidance for COVID-19 diagnostic testing.
  • The first version of this document was developed by the PHAC at the beginning of the pandemic and reflected the evidence and priorities at the time, e.g. focus on travellers as primary driver for testing, limited capacity of provincial laboratories.
  • The current version has been updated to reflect current evidence and priorities and will continue to be updated as the situation evolves.
  • The majority of the recommendations are aimed at symptomatic individuals.
  • The role of testing in asymptomatic individuals is under discussion.
  • The document allows the flexibility for provinces and territories to adjust their testing strategies based on the course of the epidemiology and their testing capacities.
  • Given the knowledge as of May 18, serology does not yet have a well-defined role in detection of active cases, and is therefore not a focus of the document.

Feedback from the expert panel

  • The objectives of testing could be more defined, as testing strategies differ depending on objectives.
    • If the objective of testing is to (1) document prevalence, then the focus is on detecting symptomatic cases.
    • If the objective of testing is to (2) control outbreaks as they occur or to (3) prevent future outbreaks, then testing of asymptomatic individuals with high pre-test probability becomes important.
  • Testing of asymptomatic individuals should be strongly encouraged in certain contexts.
    • In hospitals and other congregate settings, where pre-test probabilityFootnote 5 is high.
    • Outbreak investigation: as soon as an index case is identified in a high-density workplace, then every asymptomatic individual in that setting is screened for detection and isolation.
    • Travellers from highly-impacted regions (once travel resumes).
  • More nuance in terms of level of risk could be included as it pertains to testing (frequency and rings of containment) of healthcare workers.
    • Many healthcare workers actually have very low risk of exposure, in the absence of an outbreak.
    • In a setting where there is evidence of community transmission or a high volume of patient transfer from long-term care facilities, more aggressive efforts to identify asymptomatic cases would be advisable.
  • The document could be revised to include considerations for pediatric cases, in line with the emerging COVID-19 linked inflammatory presentations observed in children.
  • Considerations could be made to move away from the theme of economic resource allocation, as the document is focused on the scientific rationale and approaches to testing.
  • There could be a section dedicated to research protocols where it is acknowledged that testing approaches may depend on the research studies being conducted. For example, a population prevalence study would include testing of asymptomatic individuals.

Other considerations regarding testing

  • When testing policies change locally, it would be helpful for that information to be noted and shared with the Public Health Agency of Canada and researchers, as those data are invaluable for interpreting total case counts and modelling risk and transmission.
  • It may be worth starting discussions about testing in the private sector to support a return to economic activity.
    • It is anticipated that companies will want to test their workforce, including asymptomatic individuals. Testing is already taking place in some essential services (e.g. waste management) and other settings (e.g. mining sites).
    • In addition to detecting potential outbreaks, testing in this setting can also reassure the workers.
    • Given that increasing demand for testing is anticipated, private testing laboratories may have an important role to play. Clarification or guidelines on how private testing laboratories can be certified for COVID-19 testing may be of benefit.