Deciding Who Gets Tested Differs across Canada, Causing ‘Chaos and Errors’

Canada has a big testing protocol problem for COVID-19 — a lack of consistency across the country, say two health researchers.

Although each province has developed self-assessment tools to help citizens decide whether they qualify to be tested or not, none of the questionnaires are the same or offers the same results, reports a new University of Ottawa study.

“Each province has devised a tool, based [on] its own case definition or perception of the scientific evidence, inevitably resulting in chaos and errors,” warns the study by Brieanne Olibris and Amir Attaran at the University of Ottawa.

Attaran, who has been highly critical of Canada’s sluggish and reactive approach to the pandemic, is a professor teaching both law and public health at the University of Ottawa.

“To use a metaphor, not only have provinces wasted resources and time ‘reinventing the wheel,’ but some of their wheels are more oval than round,” writes the study’s authors.

In addition, “some provinces have developed their tools at variance with medical evidence, and these tools negligently furnish disinformation on a potentially deadly illness.”

After the 2003 SARS outbreak, which caught Canada off guard, the provinces and federal government agreed to have a coordinated pandemic response.

But that doesn’t appear to have happened with COVID-19.

“The failure to have a single, federal self-assessment tool — or multiple provincial tools all conforming to a single standard of care — is proof coordination has failed,” said Attaran in an interview with The Tyee.

As the pandemic progressed, each province developed its own questionnaires generally designed to screen for four things: symptoms, exposure, medical conditions and travel history. The goal is to limit testing to those most in need.

But no province currently asks citizens requesting a test if they are experiencing the whole gamut of symptoms as described by the WHO: fever, dry cough, fatigue, sputum production, shortness of breath, sore throat, headache, muscle or joint pain, chills, nausea or vomiting, nasal congestion, diarrhea, coughing of blood and conjunctivitis.

Saskatchewan and Newfoundland and Labrador, for example, only screen for fever, cough and shortness of breath.

Until the Ottawa study was completed, Nova Scotia’s tool only considered travel-associated risks and entirely omitted community transmission. (It is now revising its questionnaire.)

Quebec was the only province that asked citizens seeking a test if they had lost their sense of smell — a sign of early infection along with loss of appetite.

The study presented each provincial self-assessment questionnaire with four invented yet possible patients — all with different symptoms and travel histories — to see if they yielded consistent outcomes.

Only a patient who had a cough and a history of travel exposure got consistent advice, namely that they should stay home and isolate for 14 days.

But patients with a headache and chills or a cough and no history of travel got totally inconsistent advice.

British Columbia, Saskatchewan and Newfoundland and Labrador told users with headaches and chills that they do not have COVID-19 symptoms.

Attaran and Olibris characterized the response as negligent advice, arguing that “were it given by a clinician rather than a computer it would be medical malpractice.”

Failure to have uniform standards across the country about who qualifies for testing can have two dramatic consequences, warned the authors.

Without consistent public health advice as to who has COVID-19 symptoms, or agreement on what constitutes a possible COVID-19 case, “there is a fundamental failure to ensure that Canadians appropriately self-isolate to mitigate community transmission, which risks causing infection and illness to others and worsening the pandemic.”

Second, consistent advice is not being given to citizens with symptoms seeking testing, which skewers data on national reported cases.

“This failure in turn introduces systematic errors into provincial counts of confirmed cases, making epidemiological comparisons between provinces inaccurate and misleading, and degrading the quality of critical epidemiological models — which Canada requires to guide safe de-escalation of social distancing, timely reinstatement of civic institutions and the economic activity, and overall a return to normalcy.”

Attaran and Olibris recommend that the federal government immediately develop a single self-assessment tool for COVID-19, in both official languages, and perhaps also languages of immigrants and First Nations.

“This would solve the immediate problem of lacking a single, evidence-based standard of care for self-assessment.”