Recommendations
The Precautionary Principle
That the precautionary principle, which states that action to reduce risk need not await scientific certainty, be expressly adopted as a guiding principle throughout Canada’s public health, employer infection policies, measures, procedures and worker safety systems by way of immediate action in: policy statements; all relevant operational standards and directions; and by inclusion, through preamble, statement of principle, or otherwise, in all relevant legislation.
That in any infectious disease public health emergency, the precautionary principle guide the development, implementation and monitoring of measures, procedures, guidelines, processes and systems for the early and ongoing detection and treatment of possible cases. That in any infectious disease public health emergency crisis, the precautionary principle guide the development, implementation and monitoring of worker safety measures, procedures, guidelines, processes and systems.
That federal and provincial/territorial governments must collaboratively act on an urgent basis to ensure that there are sufficient supplies of N95 respirators, or better, or equivalent, to ensure that all health care workers can be protected at a precautionary level. This must include maintaining and regularly refreshing strategic stockpiles and developing a made-in-Canada supply chain.
The precautionary principle should be the primary driver in setting and properly maintaining levels of personal protective equipment in national and provincial stockpiles. Stockpiles should be set and maintained at levels that ensure that all health care workers are protected at an airborne level. Building on its contracts with 3M and Medicom to produce N95 in Canada, the federal government should ensure that Canada has sufficient domestic production capability to protect health care workers at a precautionary level.
When a new pathogen emerges – and experts believe COVID-19 is not the last time we will face this threat – health care workers should be protected at a level consistent with the precautionary principle. This precautionary requirement should be enshrined in all occupational health and safety legislation.
Chief medical officers of health (CMOHs) should be statutorily required to consider and apply the precautionary principle in assessing their jurisdiction’s public health emergency preparedness, thus ensuring that their health care workers are protected at a precautionary level.
Decisions to forego the precautionary principle should not be taken arbitrarily, with a lack of transparency, or without the concurrence of health care worker unions and workplace safety experts. Decisions to forego the precautionary principle should be reviewed by relevant legislative committees and auditors general.
That the health and safety concerns of health care workers be taken seriously, and that in the spirit of the precautionary principle, health care workers should also feel safe.
Canada should critically assess WHO guidance on worker safety and pandemic containment through the lens of the precautionary principle, and determine whether it is in Canada’s best interests and reflects the best evidence from other countries’ natural experiments, and emerging scientific evidence.
Worker Health and Safety
Canada should immediately add occupational hygienists, worker safety experts and aerosol experts to PHAC and jointly develop guidance that exercise the precautionary principle and accepts and consider diverse sources of evidence, not just randomized control trials.
On worker safety and pandemic containment measures, Canada should have the resources and capabilities, including sufficient worker safety and aerosol expertise, to independently assess guidance from the WHO and to formulate our own.
A formal national health care table should be established involving health care unions, employers and the PHAC, with a legal requirement for the PHAC to consult that committee in a transparent and meaningful manner before finalizing guidance on infectious disease response.
Guidance on the safety of health care workers be made on a precautionary basis by workplace regulators, health care worker unions and worker safety experts working collaboratively, and that those decisions form the basis of health worker safety guidance issued by public health agencies.
Ensure that provincial labour ministries have the resources and ability to act independently from provincial health ministries and fully enforce occupational health and safety laws.
That provincial ministries of labour use their enforcement and standard-setting activities, and ministries of health use their funding and oversight, to promote organizational factors that give rise to a safety culture in health workplaces.
That in any future infectious disease crisis, ministries of labour have clearly defined decision-making role on worker safety issues, and that this role be clearly communicated to all workplace parties.
That provincial ministries of labour have the capabilities and resources to safely, effectively and comprehensively conduct in-person, on-site inspections during public health emergencies.
Establish a worker safety research agency as an integral part of the Public Health Agency of Canada with legislated authority for decision-making on matters pertaining to worker safety, including the preparation of guidelines, directives, policies, and strategies. It would be modeled on NIOSH, an essential part of the U.S. CDC, and would be focused on worker safety and health research, and on empowering employers and workers to create safe and healthy workplaces. Like NIOSH, its staff would represent all fields relevant to worker safety, including epidemiology, nursing, medicine, occupational hygiene, safety, psychology, chemistry, statistics, economics, and various branches of engineering.
In the interim and on an urgent basis, any section of the PHAC involved in worker safety have, as integral members, experts in occupational medicine and occupational hygiene, and representatives of workplace regulators, and consult on an ongoing basis with workplace parties.
Accountability, Transparency and Independence
It is important that Canadian ministers and senior public health officials continue to participate in relevant WHO decision-making bodies. However, to preserve Canada’s independence, Canadian participants in policy and Canadian guidance-making bodies should not wear two hats. They should either participate in policy and guidance making at the WHO or at Canadian public health agencies, but not at both.
Federal and provincial chief medical officers of health (CMOHs) be statutorily required, on an annual basis, to report to their respective legislatures, and to the public that they’re mandated to protect, on the state of their jurisdiction’s public health emergency preparedness, and make recommendations on addressing any shortcomings. The preparation of this report should reflect the concerns and perspectives of health worker unions and safety experts.
The reports of the CMOHs be required to go to a standing committee of their respective legislatures, which will hold annual hearings into the report and related issues.
Chief medical officers of health be given the statutory independence – in jurisdictions where they do not have this right – to speak publicly on vital issues like pandemic preparedness without fear of political interference or retribution.
Qualified outside auditors with sufficient expertise and resources independently audit, on a biannual basis, CMOHs’ preparedness resources and their statutory declarations on pandemic preparedness, and publicly report their findings.
That all jurisdictions be required to publicly report to their stakeholders – and to the federal government – in a consistent, detailed and timely manner the number of health care worker infections in their area.
Governments and public health agencies be open and transparent on levels of PPE stockpiles.
With regards to efficiently and cost‑ effectively maintaining stockpiles of PPE, governments may want to consider Taiwan’s three‑tier stockpiling framework. It has proven its ability during COVID-19 to optimize the PPE stockpiling efficiency, including through regular cycles of refreshing, ensure a minimum stockpile, use the government’s limited funds more effectively, and achieve the goal of sustainable management.
That significant good faith effort be made to iron out federal-provincial jurisdictional conflicts hindering timely data sharing on health care worker infections.
That Statistics Canada be given the authority and resources to implement and operate a transparent national system on health care worker data. The resulting data sets must have consistent terminology and criteria. They must have significant granularity to allow monitoring and trend analysis by occupation and sector at a detail level (e.g., PSW, nurse, physician; or LTC, nursing homes, hospitals, pandemic wards within hospitals, direct patient care and other key roles such as triaging). The data has to be shared in real time, not delayed by weeks or even months. And the performance of the system must be monitored and tested regularly.
Long-term care
Fixing an historical anomaly, the Canada Health Act should be amended to include long-term care, making it available to Canadians on a universal basis. Government programs aimed at assisting Canadians with long-term care needs vary by jurisdiction and typically are income-based. This is not consistent with the principle of universality at the heart of Canada’s publicly funded health care.
Convene a national commission to develop short-, medium- and long-term strategies for the structure of the long-term care sector in light of the shortcomings revealed by COVID19.
Develop and implement a long-term care labour force strategy to address the multiple labour force problems revealed by COVID-19, including the problems of inadequate compensation, staff shortages, overreliance on part-time staffing, and training failures.
Improve wages, benefits (including paid sick leave) and conditions of employment for health care workers in the long-term care sector to levels that commensurate with the social importance of their work, the complexity of their duties and the daily hazards they face, even in non-pandemic times.
Offer all part-time workers in this long-term care sector full-time employment (with full-time wages and benefits) and limit their work to one single facility.
Examine best practices of jurisdictions like South Korea, Hong Kong and Singapore that have a strong track record of limiting COVID-19 in their long-term sectors. In South Korea, for example, anyone with suspected COVID-19 is immediately isolated and moved out to a separate emergency quarantine centre or hospital. In Hong Kong, all long-term care facilities have, as a minimum, a three-month supply of N95 respirators and other PPE. Also in Hong Kong, all long-term care facilities conduct emergency exercises every year to coincide with the advent of flu season to ensure infection control measures and resources are in an acceptable operational state.
Because systemic infrastructure shortcomings limit the ability of many long-term care facilities to isolate COVID-19 cases, it is vital that on an urgent basis separate emergency isolation facilities be created, resourced and staffed. This would permit COVID-19 cases to be transferred out of long-term care facilities that are unable to isolate them.
Ensure that any surge in COVID-19 hospitalizations does not result in shifting patients to already overburdened, under‑resourced, and understaffed long-term care facilities, who may be unable to isolate new admissions.
Reflecting a best practice developed in the U.S., consider establishing, where space and resources permit, a cohort unit for exposed and new admissions as an effective way to separate and screen higher risk individuals for the 14-day incubation period. Keeping these patients on isolation and with dedicated staff would make contact tracing for exposure identification easier.
Ensure that all long-term care facilities are staffed by a dedicated infection control professional with occupational health and safety training. Require that professional to provide quarterly, publicly accessible assessments of the state of infection control and occupational health and safety at their facility.
Ensure that relevant workplace regulators conduct in-person, proactive inspections of all long-term facilities to ensure compliance with occupational health and safety laws, regulations and best practices.
On an urgent basis, ensure that all health care workers in the long-term sector are properly trained and fit-tested on the use of N95 respirators and other protective equipment.
All sectors (community, acute and long-term care)
Respect and enforce the health and safety rights of workers.
Ensure workers have the right to participate in decisions that could affect their health and safety.
Ensure workers have the right to know about the hazards in their workplace and receive the training they need to be able to do their jobs safely. Ensure workers have the right to refuse work that could endanger their health and safety or that of others.
That the right of health care workers to speak out about unsafe working conditions be protected from retaliation by their employers.
Ensure adequate supplies of personal protective equipment (PPE), including N95 respirators or better (e.g., elastomeric respirators), and that workers and essential family visitors have access to appropriate PPE.
Recognizing that while sufficiently protective, N95s have their drawbacks, including comfort, the federal and provincial governments should collaborate on standards and sufficient supplies of alternative respiratory protective equipment, like elastomerics, that protects at the same level or better than N95s, and that, evidence suggests, may have comfort and cost advantages.
Provide hands-on training on infection prevention and control, including training testing and drilling workers on donning, doffing, safe use and limitations of PPE – for all workers and essential family visitors working in and entering long-term care homes.