Did Canadian health officials act fast enough to curb community transmission of COVID-19? This week’s growth in positive tests, from people infected earlier in March, suggests they did not.

While infectious disease experts say it is believed Canada had community transmission as early as March 1, governments did not bring in “physical” or “social” distancing guidelines until the middle of March, and emergency orders to close businesses until the tail end of March.

In Ontario, Premier Doug Ford even encouraged people to enjoy themselves on March break holidays on March 12, which shocked experts in the infectious disease field. In Quebec, health officials in Montreal have recently begun contact tracing of people suspected of spreading the infection on public transit as early as March 6. Across the country, there has been growing concern of spread of the disease at conferences, including a mining conference and a dental conference early in the month. A Toronto synagogue was closed for cleaning over fears of COVID-19 transmission from a visitor on March 9.

“Certainly for the entire month of March we have had local transmission going on,” said Dr. Michael Gardam, an infectious disease expert and chief of staff at Humber River Hospital in Toronto. Gardam is a veteran of other outbreaks, including SARS (2002 to 2004).

“I think all of us who have been involved in this have felt that we likely had local transmission going on very early on at a low level but obviously as you import more travel-related cases and as they spread to others and those spread to others then local transmission becomes a much bigger thing,” Gardam told the Star.

The question of whether Canadian officials acted in time reveals a tension between concrete evidence of local transmission and educated deductions based on how outbreaks typically spread and how COVID-19 was known to be spreading internationally.

Public health officials say they need firm evidence — confirmation of close contact between a known positive case and another person who has tested positive — before they can announce local transmission. Compounding the problem is that this particular disease, experts say, can “shed” the virus before symptoms present, during, and for roughly a week after. A person with COVID-19 could transmit the disease for roughly a month.

Here’s the timeline in Canada.

According to the World Health Organization’s own records, a Canadian federal official contacted the WHO on March 1 to inform the agency that Canada, like China, Italy and other countries, had confirmed local transmission (as distinct from an infected traveller returning home and testing positive).

Neither the WHO nor Canadian officials will say which part of Canada made that report on March 1, but experts say it likely came from a cluster of cases in a nursing home in B.C.

To put that March 1 date in perspective, the Toronto Maple Leafs had the night before defeated the Vancouver Canucks 4-2 and were looking forward to a winning record in the last weeks of the season. The phrases “social distancing” and the now preferred “physical distancing” were not part of everyday jargon and at all levels of school in the country it was business as usual.

Ontario reported 16 cases by March 1, 14 listed by the province as travel related — people who had arrived in Canada from Iran, Egypt and China. The other two cases, the province did not list the nature of the transmission.

Over the next 10 days, leading up to March break across Canada, media reports show a rising level of concern, but the focus was still on travel. Would you get COVID-19 by travelling, and was it still safe to take a trip with the family on March break?

At this point, no public health agency in Canada had stated publicly that it had confirmation of local transmission of the virus, beyond the original B.C. report.

But there were signs that the virus was out there.

In Toronto, the Beth Sholom Synagogue closed for cleaning March 9 after a lay leader who had been to a Washington, D.C. conference became sick and tested positive for COVID-19. Other members of the synagogue went into self-isolation, as did a Toronto councillor, who had a conversation with the lay leader previously, on March 5.

Around this time, a Sudbury man tested positive and it was believed he may have contracted the virus at a March 2-3 mining conference in Toronto.

And, according to B.C. health officials, it is now known that about 20 people tested positive after attending a March 5-7 dental conference in Vancouver. One dentist who attended the conference has since died. B.C. health officials have not said if the man died of COVID-19 but the man’s friends have told the media that he was very healthy prior to the onset of symptoms.

With politicians across Canada struggling to come up with a clear plan on what to tell the public, Ontario’s premier on Thursday, March 12, urged parents and their children to go away on March break and have a “good time,” though Ford also commented that things were daily related to the disease.

By the time Ford made those comments, public health officials were sounding alarms and suggesting travel might not be wise. But still, the public was being told by health officials that community transmission was at a low risk.

By the night of Thursday, March 12, it began to change. First Western University in London, the University of Toronto, Dalhousie University in Halifax and universities across the country closed and made plans to go online. Elementary and secondary schools, at the direction of provinces, followed suit, telling people students would not be coming back after March break.

Still, stores and malls were open. Starbucks and other coffee vendors instituted a policy preventing people from using their own mugs. People sat at tables in restaurants as they always had.

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On Saturday, March 14, Alberta health officials confirmed their first case of community transmission.

On Monday, March 16, Toronto’s medical officer of health confirmed community transmission, and other agencies across the country began to issue similar confirmations.

“Physical distancing” was by then in the jargon, with people told to stay two metres from each other — the distance the virus could travel following a sneeze or a cough.

Work from home began for many. More recently, an increasing number of rules have been put in place, closing all but the most essential services and stores. You can go to the drugstore, buy food, beer and liquor, but you cannot go sit at a restaurant or coffee shop, or buy clothes in a store. Dog walkers, barbers and a myriad of other workers were told to stay home in Toronto and other cities in a bid to stop community transmission. Wednesday, in Toronto, sports fields were closed, even to the most casual athlete wanting to dribble a ball.

Why did it take so long?

Gardam said at the start of the outbreak public health officials and doctors were focusing on travel cases and “not doing surveillance early on for local transmission.”

Even though, as Gardam says, “there is no way we were not going to have local transmission. There’s no way Canada would be different than any other place in the world.”

Public health officials have said that in doing contact tracing, it is sometimes easier to confirm a travel-related case than a community transmission case.

“Because we were basing our screening on travel, we weren’t looking for them. When we started to look for people with symptoms, that is when we started to pick up local cases,” Gardam said.

As to why governments across Canada waited several weeks to bring in tough rules, Gardam said that is typical of an outbreak.

“It is a very difficult thing for governments to do (bring in tough rules like shutting down businesses or even strict social distancing guidelines) because they have to bring it in almost before you think you need to,” Gardam said.

“By the time you have seen evidence of community spread, presumably that is just the tip of the iceberg. The horse is already out of the barn,” Gardam said.

“You need to bring it in as soon as you possibly can but what countries tend to do is bring it in later and in a stepwise fashion. You are not too strict in the beginning and then you are more strict and then you are more strict and each time you are doing that a week has gone by and you had even more transmission and remember, transmission is exponential.”

Some provinces have also struggled with their testing capacity, including Ontario, which was only as of Wednesday beginning to clear its backlog of tests. As of Wednesday, Ontario still had more than 10,000 tests for which there were no results. And testing parameters have changed in Canada in the past week, with a focus now on health-care and other front-line workers, and the very sick. Experts say there is a chance more community transmission cases will be missed as a result.

On Tuesday, March 24, Dr. Theresa Tam, Canada’s chief public health officer, announced that community transmission had overtaken travel as Canada’s primary source of virus cases. The Star posed questions about the speed with which health officials confirmed local transmission. Federal officials and officials in Ontario and B.C. did not respond. A senior Alberta official told the Star there was “no evidence” of local transmission prior to March 14. Until that time, all of their cases were recorded as travel or close contact, meaning a person (spouse or other family member) who was infected.

A Quebec official said that province had no evidence of local transmission until recently. Public announcements about areas where people might have been infected, including public transit as far back as March 6, were only made recently as public health officials acted on confirmed tests and started doing contact tracing to see if other members of the public were at risk.