‘Listen to the front-line people’: An infectious-disease doctor on COVID-19 in schools

TVO.org speaks with Michael Garron Hospital’s Janine McCready about variants of concern, testing — and how to keep schools open
By Nathaniel Basen - Published on Mar 09, 2021
Janine McCready is the associate director of infection prevention and control at Toronto’s Michael Garron Hospital. (Courtesy of Janine McCready)

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As Ontario starts the next phase of its COVID-19 immunization campaign, experts are predicting a surge in new cases driven by so-called variants of concern.

Janine McCready, an infectious-disease doctor at Michael Garron Hospital, in Toronto’s east end, is involved with the community’s coronavirus response in multiple ways. At the hospital, she manages the treatment of patients with infectious diseases, including COVID-19. And she’s its associate director of infection prevention and control, meaning she works to prevent the spread of the virus within the hospital.

She also works with patients outside the hospital, including by running preliminary contact tracing — and spearheads efforts to keep schools in Toronto’s east end safe, by running initiatives such as education campaigns and take-home COVID-19 testing. Many of her efforts have been focused in the Thorncliffe neighbourhood, which has seen disproportionately high rates of infection throughout the pandemic.

TVO.org speaks with McCready about the situation in her hospital, what schools need in order to stay open — and what she’s learned this past year.

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TVO.org: How are you doing?

Janine McCready: Doing okay. Being an infectious-disease doctor during a pandemic, it’s kind of a double-edged sword. You at least feel like you have a little bit of control over the situation or at least understand or can maybe see what’s coming — but it’s exhausting. I wish I could somehow spend less time working and more time with my family. But this is hopefully a once-in-a-career pandemic. I’m lucky to have really good colleagues and amazing support from the hospital to be able to do the work that we need to do. So, overall? Doing okay.

TVO.org: I certainly hope it’s a once-in-a-career situation. This week, you’re on call at the hospital. How has the treatment of COVID-19 patients changed?

McCready: From the beginning until now? At least we have some very effective drugs to treat people. That’s amazing, because, in the first wave, we felt very helpless. All we could really offer people was to try to get them to lie on their stomachs, prone, and then just really hold their hands and support them and try to help them connect with their families via Zoom. Really, just cross your fingers that they were going to get better — because we didn’t have any effective treatments. So that was very discouraging. It was awful, because there were a lot of families that would come in, and you would have, you know, mom and dad, and one of them would pass away and the other one would still be admitted upstairs, and no one could even come in and see them and comfort them because they were still in isolation. One of my physician assistants attended a patient’s husband’s Zoom funeral with her, sitting there in her hospital room with her, because she didn’t have anybody else.

I don’t think a lot of us have fully processed it — it was not nice. So now, there’s still, unfortunately, COVID; it’s still a horrible disease, and the medicines aren’t perfect. But at least we do have some therapies that are effective and do reduce mortality. At least we feel like we can offer them something. There are still a lot of people that don’t respond to the treatments and do quite poorly, but it’s much better than it was in the first wave. Still, it’s discouraging to see the number of cases coming in.

TVO.org: What is the state of things in your hospital right now?

McCready: The last few weeks, things had begun to kind of settle down. But then, just yesterday and the day before, we had about eight new patients with COVID come in over 24 hours — which is a little bit anxiety-provoking. Everyone’s been talking about this third wave starting. During mid-January, we were getting probably five to 10 new admissions with COVID each day, and then it really trickled down. For a few days, we were getting one or zero or a couple — and then over this weekend, it was basically eight a day. So it’s not overwhelming the hospital at this point, but there are a lot of cases still out there. It’s a bit worrisome with the rise in the variants of concern. And then with different parts of the province reopening a little bit — I am more worried now than I had been earlier on that, because the hospitals were already at surge — it’s already full. If we start seeing a flood of cases coming in, it’s going to be challenging.

TVO.org: What kind of work are you doing with schools?

McCready: There’s a lot to delve into. We’ve been doing this school-support program since August, and, so, on a day-to-day basis, a lot of it is touching base with schools, touching base with the principals. If they have any questions, a lot of them have my email and my phone number and they just text me if they have questions or if they’re concerned about something.

And then we organize pretty much all the testing related to 110 schools in east Toronto. So, basically, if there’s a case identified, our team helps to organize testing — whether it’s through one of our pop-up clinics that we set up to accommodate the needs of the community or whether we actually go on-site and do testing or whether we bring kits to the school and get them to do take-home testing. We work with the school to see what works best. This morning, I had a meeting with the schools to organize testing for a full school, and then we’re also running a program to do asymptomatic testing. As you probably heard from the minister of education, we wanted there to be testing of kids that don’t have symptoms, so we’re running a testing program for that across 10 of our schools in higher-prevalence areas. Then there’s following up on those results, helping with the logistics of that.

In terms of other school-support-type things, once every two weeks, I do a forum for the school principals and teachers so that they can ask their questions directly to me. Anything related to COVID. I do a brief overview of things in the news, and then they just ask any questions. We’ve been doing that since August, first with just the principals, and then we opened it up to some of the teachers. We are also running a couple of pilot programs doing something called an IPAC [infection prevention and control] Champions program in schools — almost like a “train the trainer” program. For some specific schools that wanted to pilot it, we did extra training for a group of teachers and admin, different people within the school, to enrich their IPAC knowledge so that they can be leaders within the school.

TVO.org: That’s a lot.

McCready: Yeah, I don’t sleep anymore.

TVO.org: A lot of your work is focused in Thorncliffe. How is that community doing with its COVID-19 response?

McCready: The schools there, and the principals, are amazing. They care so much about their community. We’re really just trying to do our best to provide the teachers and the principals and the parents with the most information we can. So we do those regular forums, but then whenever they need an extra one, just for their staff, we do a Zoom thing for them. And then, also, I try to attend a parents’ forum every two weeks to answer questions for the parents.

As you see the numbers rise, we see cases enter the school. One of the challenges is that, every time you have a case enter the school, even if it doesn’t cause transmission, it disrupts the in-class learning: that class then has to be isolated for 14 days, and their siblings now also have to isolate. It’s a health concern, but it’s also a disruption of their education, which is really challenging.

One of the other things we’ve seen is that if you compare Thorncliffe to a community with lower rates of COVID-19, other parents have been less likely to enrol their kids in online learning. So, for a variety of reasons, in some of the schools now, in-person enrolment has dipped below 50 per cent. That decision for each family is a complicated decision, but it’s a bit heartbreaking that the kids aren’t able to attend school and that the parents don’t feel that it’s safe for them to attend school — or that it’s just not practical, because education is disrupted with on-and-off in-person learning. Compare it to other communities, where the in-person enrolment is higher than 80 per cent.

As we’ve seen with everything COVID, the communities that need the most support are continuing to get hit the most at every level. Even the kids’ education is being impacted.

TVO.org: If you were to suggest one or two things — maybe it’s certain investments or policies — that this school system needs, what would they be?

McCready: It’s really tough. The schools have done a very good job.

I’m not in a position when it comes to the logistics and implementation and looking at things across the system. But I think if you look back, maybe just for the kindergarten school (they’ve got a whole school that is all kindergarten kids) — for those kids, the class sizes are smaller, but every time you have an exposure, that’s 15 to 20 kids that have to go home, and then their siblings have to go home. Would it have been worthwhile to pilot a strategy where you really looked at reducing the class sizes, just for the communities that have really high prevalence? You make them classes of 10, when the numbers in the community are very high?

One, it’s going to prevent transmission, and two, it’s going to minimize exposure so that the kids aren’t Ping-Ponging in and out of school. It’s a hard thing: I’m not at that policy level, and the implementation would have been incredibly challenging. But that would have been one thing that maybe would have made parents feel more comfortable, and maybe it would have made them feel like they were a priority, which I think they deserve.

But, stressing, it’s easy to say, and it’s another thing to actually implement.

And then one thing we’re doing now, which I’m glad we’re doing now, is some form of asymptomatic testing. It would have been helpful, probably, to do it in the fall, but I think we had to learn from what happened.

What we found in the fall was, as cases were rising, we’re finding cases, and then we did the full-school testing at some of these schools — we found many cases of clinically asymptomatic kids that were at school with COVID. And that really was, I think, a big shock to the community. What we’ve tried to do this time around is to do asymptomatic testing throughout the school, starting from the beginning of when schools opened, so that each week we’re testing some kids, so we have an idea of what’s actually happening at the school level and can provide feedback to the school, the teachers, and the community. That gives us a head start, and we don’t have to wait to find the kids with symptoms or the parents getting sick. I’m hopeful that helps to prevent spread but also give us a head start if we start to see cases rising, and then we’re not playing catch-up.

TVO.org: In the community, we’re seeing increased prevalence of the variants of concern. Are Toronto’s schools ready, and what do they have to do to prepare?

McCready: We know that the regular control measures like wearing masks, distancing, all those things, they will prevent it. It’s a question of, in the school environment, how well can you do all of those types of things?

Some schools have started to say: if kids can’t distance outside, wear a mask. They’re really trying with all those health and safety practices. And then the screening the province has done is down to one symptom — in the fall, there was some back and forth on if patients with runny noses can still go to school if they’re feeling better. But now they’ve rolled back to, any symptom, you need to stay home or go get a test. I think that’s essential, especially with the variants.

Also, if anyone in your household is unwell, then you can’t come to school: that has been huge in preventing a number of cases going to school. Certainly, when we call families and we find that the dad had symptoms and then they kept the kids home from school — that’s amazing. That’s a win. Because, otherwise, not only would you be worried about transmission, but then those all those classes of those kids would also have to be isolated for 14 days.

And then making testing easier. One of the things we’ve really tried implement since school started is a take-home strategy. We know that people are tired of getting tested. We know it’s challenging, no matter how close we put the pop-ups to people’s houses. What we’ve done is, in all of our 110 schools in the east, we have given them these take-home kits. It’s the same quality lab-based PCR test, with a swab that goes in your mouth and your nose to make it easy for parents to get the kids tested. So if anyone’s symptomatic in the house, you’re sent home from school, and you get one of these kits. Or if you’re in a class that is exposed, you get one of these kits.

So far, just from the cases that we’ve seen in the last few days, there certainly have been a number of cases that we’ve identified that got tested faster than they would have otherwise. They’re saying, “I had this kit. So we just did it, and we dropped it off on the way home.” We’ve really tried to make that easier, because I think we’re finding the cases faster. Everything has room for improvement, but so far it’s working really well.

TVO.org: Working so closely with schools is new for you in your career. What have you learned? Or what has surprised you?

McCready: It’s been incredibly rewarding. We’ve done a tremendous amount of work with different things in the pandemic, but I think the schools and the principals and the teachers and the parents — everyone just wants to do their best. It’s been really amazing to see how hard all the principals and the teachers are working to try to do what’s best for their schools. That’s been really inspiring, and they’re so appreciative. We’re just trying to do what we can to help, and they’re so appreciative of that support. It keeps me going, to be honest.

I’ve learned a lot about relationship-building and the importance of local context. What works in one community doesn’t work in another, and what doesn’t work in one community doesn’t necessarily mean you can’t still try it in different ways. I don’t think there’s a one-size-fits-all approach even for my different communities in Toronto, let alone right across the system.

We’ve made a lot of strides working with the boards; we’ve learned a lot together that you do need a very local approach in some cases. And that really helps maximize the benefits. I think it’s listening to the voices on the ground and to the parents and the teachers and the principals: listen to the front-line people — that’s what’s really been clear in this.

We’ve drawn on that as we built this case-management team. Basically, what that means is when we get a positive case, telling them, “You need to isolate” is one thing. But how do they do that? If you have no income, and no way to get groceries, what does that look like? So we have a team that we then can refer those people to, that will drop off groceries for them; they’ll help them apply for financial support and help them through that period. A lot of the connections we’ve made with the communities — and there’s still lots of room for improvement, and it’d be amazing if there were actually paid sick leave, and things like that, to make things easier — but we’ve tried to fill the gaps that we’re hearing from people actually living this experience.

TVO.org: Is there anything else you’re seeing in your work that you think people need to know?

McCready: What’s my soapbox for today? Recognizing people are tired of this, and people just want to get out of this as fast as possible, and we can almost see the finish line with how amazingly effective the vaccines are — but just not to loosen up too quickly. I really worry that we’re just in a bad spot right now, with the increasing variants of concern. The vaccines are almost there — you feel like you can touch them — and it would be such a waste. If we can just hold on for a few more months, we can save like a lot of lives. If we open up too fast, I do worry what the next two months are going to look like. As much as it’s the same message that’s so frustrating, let’s keep minimizing our contacts and doing all the right things and, I think, prioritizing trying to keep schools open.

I think it’s going to be a challenging ride, the next few months. But, hopefully, if everyone limits their contacts and still follows advice, we can do our best to keep schools open and minimize the impact on the community and the impact on families and in-patient admissions and deaths.

This interview has been condensed and edited for length and clarity.

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