As hospitals across Canada scramble to keep up with the fast-moving coronavirus outbreak, health-care workers returning from international travel this week have received varied and constantly-evolving instructions on how long to self-isolate — or, until recently in Ontario, even whether they should self-isolate at all.

Ontario Health Minister Christine Elliott told reporters at Queen’s Park on Wednesday she would be sending a directive to hospitals and other health-care providers “shortly” to ensure all those returning from outside Canada would self-isolate for 14 days.

Until then, there was no overarching policy in Ontario, where some health-care workers — including those at 12 hospitals and health-care facilities in the Toronto area — had been told they didn’t need to self-isolate before returning to work if they were asymptomatic.

The exemption had caused concern among some health-care workers and was out of step with the guidelines in place for those in other provinces — as well as for the broader public.

In a bid to stop the spread of COVID-19, the Canadian government instructed all travellers returning from outside Canada to self-isolate for 14 days, which means not leaving the house except in urgent situations, such as seeking emergency medical care. The request applies to everyone, even those who show no symptoms of the virus, which include dry cough, fever and shortness of breath.

Developing guidelines for those on the frontlines of the pandemic is more nuanced. The system must strike a balance between isolating health-care workers and ensuring there are enough doctors and nurses at the ready, particularly as the number of infected patients grows. And it makes sense that guidelines for health-care workers in densely populated urban centres may differ from the instructions in rural areas, where there are fewer medical professionals and limited resources.

However, in this crucial stage of the outbreak, when public health officials are urging social-distancing and self-isolation to flatten the curve of infection, some of these instructions, and inconsistencies across the country, caused concern among health-care workers.

In Toronto on Monday, Dr. Kevin Smith, the President and CEO of University Health Network (UHN), fielded a question from staff during a virtual question-and-answer session about why UHN’s self-isolation policy differed from what Toronto Public Health officials were recommending. He said the guideline for health-care workers returning from international travel not to self-isolate was developed with input across all Toronto Academic Health Science Network Hospitals, which also includes Sunnybrook Health Sciences Centre, Sinai Health System and the Centre for Addiction and Mental Health.

“We had a very robust debate and discussion, which included public health at every level. The view was and is that the importance of ensuring continuity of clinical service suggests that if you’re asymptomatic and a health-care provider, the system needs you at the moment,” Smith told staff on Monday, adding that some hospital staff would be able to work from home later this week, when the UHN ramps up “virtual care.”

Following the announcement at Queen’s Park on Wednesday, Ontario’s Chief Medical Officer Dr. David Williams acknowledged there are human resources issues with mandatory self-isolation in this circumstance, but said “that’s our current stance.”

Williams said the variety of policies in place on self-isolation for health-care workers in different hospitals has been a “problem” and the province is looking for a more “consistent” approach.

On Tuesday, one doctor who works in a hospital outside the GTA told the Star those returning from international travel had been told to adhere to the two-week self-isolation period; doctors at another hospital outside the city were being told to self-isolate for seven days. Doctors there were told there would be no expedited testing for COVID-19 among health-care workers.

Not all health-care workers in Ontario agreed with the exceptions.

Doris Grinspun, CEO of the Registered Nurses Association of Ontario, told the Star on Tuesday she was being inundated with emails from nurses upset that some of their health-care colleagues were being told they can return to work after international travel.

“People coming from abroad, all of them, they absolutely need to self-isolate for 14 days,” she said. “If they don’t, we are otherwise at risk right from the get-go. We risk other health-care professionals getting sick.”

One of the new cases reported in Ontario on Tuesday was a health-care worker in her 20s who travelled to Las Vegas recently and was on the job at the London Health Sciences Centre, interacting “closely” with patients and staff while showing symptoms, according to the local health unit, which is tracing patients and other contacts.

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Winnipeg-based epidemiologist and health-policy expert Cynthia Carr said it makes sense in some cases to create different containment guidelines for health-care workers than everyone else during an outbreak. However, she said a lack of consistency and transparency can lead to fear and distrust.

“We need to calm down, give people time to think and pursue evidence-based decisions so we’re not getting constantly conflicting messages because government is feeling pressures to make decisions on the fly,” she said, urging the ministers of health across the country “to get together and make a plan.”

The new guideline in Ontario now more closely mirrors the instructions in Saskatchewan, where the province’s health authority issued a directive on Monday saying health-care workers returning home “were required to self-isolate for 14 days.”

The directive notes that the Saskatchewan Health Authority can waive this exemption “in situations where the health-care worker is deemed essential … to provide services for the patients, residents and clients we serve.

“The SHA aims to apply the exemption only when necessary in order to minimize risk to patients and staff,” according to the directive a ministry spokesperson shared with the Star on Tuesday evening. “No exemptions have been applied for any Saskatchewan Health Authority staff or physicians at this time.”

Guidelines for health-care workers in Alberta changed in a matter of hours on Tuesday, moving from a two-week self-isolation period for those returning from international travel to a new, less-restrictive policy, the details of which were still being hammered out that evening.

“We are finalizing mitigation measures for all health-care workers coming back to Alberta from out of the country. These will ensure that their health and the health of patients is protected,” Tom McMillan, assistant director of communications for Alberta Health, said in an email late Tuesday. “If they follow these measures and are feeling well, they will be able to work. More details will soon be communicated to health-care workers.”

In British Columbia, Provincial Health Officer Dr. Bonnie Henry recently sent a letter to hospital workers stating: “We are asking health-care workers who return from travel outside Canada and are not essential to the delivery of patient care to self-isolate at home for 14 days.

“Health-care workers who return from travel and are essential to the delivery of patient care may return to work but should take additional precautions to reduce the risk to their patients, colleagues, and the public should they become symptomatic.” The letter did not provide explicit details on who is considered essential.

As of Monday at 4 p.m., the Nova Scotia Health Authority policy was that any employees returning to Canada after March 13 at noon “must self-isolate for 14 days and self-monitor for symptoms,” a government spokesperson said in an email.

As part of that self-monitoring, employees must take their temperature twice daily to ensure it is not greater than 38 degrees and assess “for development of cough, shortness of breath or other symptoms including fatigue, muscle aches, headache, sore throat.”

An employee developing symptoms “must call the toll-free Occupational Health number” to be screened by an occupational health nurse.

In Quebec, as of Wednesday morning, health-care workers and physicians were being told to follow the same guidelines in place for other members of the public, and self-isolate for 14 days when returning from international travel. That policy has been in place since March 12.

On its website recommending a two-week self-isolation period following international travel, the Public Health Agency of Canada states “some provinces and territories may have specific recommendations for certain groups such as health-care workers.”