The home stretch, Part 1: An infectious-disease doctor on our new normal speaks with Zain Chagla about the Delta variant, de-escalating risk — and what we need to remain alert for
By Matt Gurney - Published on Jul 19, 2021
Zain Chagla is a consultant physician at St. Joseph’s Hospital and Hamilton Health Sciences. (The Agenda)



Sometime in the next few weeks, Ontario’s vaccination campaign will be essentially complete. It will not end, because there will be stragglers and new people aging into eligibility. But the main effort is only weeks away from completion. We will move into what military commanders would call the “mopping up” phase — the main fighting will be over, even if some skirmishes continue for some time.

This may not represent a final victory — we will need to remain vigilant against new variants that may defeat our vaccines. For now, at least, a return to something much more like normal is possible. Only time will tell what that new normal looks like, and that’s a topic for future analysis. The challenge (and opportunity) before us right now is different: What does this next phase look like? These coming weeks and months? What should we do right now, as we exit this long crisis?

In the coming days, will present interviews with a variety of experts who were all asked some variation of this question: What happens next in your field, and what must we do immediately? First up, public health, with Zain Chagla, an infectious-disease doctor and professor at McMaster University. 

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Matt Gurney: Doc, let’s start with an extremely basic question, and you can run with it. We’ll wrap up the vaccination campaign later this month, maybe early next month. [dramatic pause] Then what?

Zain Chagla: It would be remiss for us to not start with this: the rollout is not going to reach everyone, right? There are people where we will have to make a very concerted effort to get them vaccinated. We won’t be able to just keep doing pop-ups and using pharmacies. We will really have to get aggressive about getting people vaccinated, giving people the opportunity to vaccinate. It’s not a surprise that we are seeing big outbreaks of the Delta variant in places and in populations that are hard to reach. Waterloo had its big outbreak among those who are homeless. We’ve had large outbreaks, even when the Alpha variant emerged, in the homeless population in Toronto, in Hamilton, in Thunder Bay. This population is going to need aggressive work. We’ll have to bring in shelter providers, emergency rooms, paramedics — all the places these people have contact with medical care. So that’s the first thing.

But after that, it’s interesting. I think we have to redefine, at the end of the day, what we’re actually watching. And that’s the interesting part of all this. Right now, you hear a lot of voices, some that are incredibly confident about “We’re back to normal!” We’re certainly watching the United States. Anyone who’s watching the NHL and the NBA playoffs is like, oh, wow, this looks like 2019. And we’re just starting to get to haircuts and social gatherings again. We are going to have to re-evaluate what fundamental things we want to monitor for. Are case counts actually going to be a good indicator of the upcoming health-care utilization and hospitalizations and deaths?

Once you get to the point where everyone who wants to get a jab gets a jab, and say 70 or 80 per cent of people have their second dose, this is really a fundamentally different disease. And we’re even now seeing with the Delta variant taking over in the United Kingdom, the mortality, even though we think it spreads more and hospitalizes people more, is paradoxically lower than all the other variants. And that’s because vaccines are working, and the population that seems to be getting hit is the younger population more than anything else, because the older population is already protected. 

We need to spend this summer asking what we want to achieve. We have sustained and suffered huge harms to maintain the health-care system and ICU capacity in the province. But do we still need daily updates on cases when they are very low? Maybe we can do weekly now? This is what we’ll need to figure out this summer.

Gurney: I want to just grab onto something you just said. And you’ve said it a few times before on Twitter, at least, that I’ve seen. “A fundamentally different disease.” What do you mean?

Chagla: Sure. Yeah. Look, the first wave of COVID, the original variant, killed about 2 per cent of people it infected. That was the case-fatality rate. Then Alpha came along. It spread more, killed more, and killed younger people. Now, in the United States, fully vaccinated people are 0.1 per cent of hospitalizations and 0.8 per cent of deaths. Ninety-nine per cent of deaths are in people who are not vaccinated. We can see this. Even in the U.K, the fully vaccinated people who are dying are over 50. No one under 50, if fully vaccinated, has died despite tens of thousands of Delta cases. Hospitalizations are mostly under-50s who are not vaccinated. 

All the characteristics of this disease that made it a pandemic, that overwhelmed hospitals and caused mass death, and was fairly indiscriminate amongst who it affected … those are reset. This disease, in a vaccinated individual, has a risk profile that’s actually pretty similar to the other respiratory infections we deal with on an annual basis. You get sick, and you miss a few days of work. Maybe the kids stay home from school. But it isn’t a disease that’s going to fill hospitals, fill the field tents, and force us to triage. People will die of COVID, even fully vaccinated people. But it’s going to be a small fraction of what we’ve seen. 

Gurney: See, that’s interesting. British Columbia and Alberta are already wrapping up daily briefings. Ontario probably will soon. But this is veering away from infectious diseases a bit and into psychology, but, wow, it’s going to be something to accept the day we can all look around and go, huh, wow, at least here, this thing is largely over.

Chagla: Absolutely. I mean, there have been a lot of associations and a lot of risk that has been built into the last 18 months. We’ve spent so much time talking about personal risk and community risk, and monitoring metrics and indicators. De-escalating risk is much harder than escalating risk. And that’s especially true now because the de-escalation is so mundane. You go to a pharmacy, get a jab, and a week or two later, COVID is a typical respiratory infection for you. It’s hard to turn that off and for people to say, actually, I am protected now, I can go back to normal. 

The United States has been a leader on this. They’ve communicated to people, if you’re fully vaccinated, you can do things. Congregate indoors. Take a mask off. We need that. We need people to know that getting vaccinated will change your life. We haven’t done enough to factor that into our messaging, to give people that sense of relief. There’s a lot to do. People have gotten used to thinking that lockdowns are how we fight this disease. It’s going to be hard work communicating to the public that the risk is different now.

Gurney: Let’s flip this around a little bit. I agree with all that above, but let’s talk about, during this exiting the pandemic period, what we do need to remain on guard for. We can’t just drop our guard instantly. What do we need to stay on the alert for?

Chagla: We need to do surveillance, for sure. We have some core populations where surveillance is important: travellers, health-care workers, hospital staff. There’s been a lot of work to make sure that samples that we send in Ontario and across Canada are sequenced so that we actually have a relatively real-time sense of what’s circulating in the world and what’s circulating in Canada. Especially with kids going back to school, we’ll need surveillance and a formal method to actually surveil them and track this stuff, so schools can operate safely. We’ll want to watch those settings, like schools, and make sure we don’t have outbreaks growing undetected. In a community with low vaccination, we don’t want to only realize there’s an outbreak when health-care utilization takes off overnight.

We have built-in surveillance networks for a lot of different diseases. We do surveillance for hospital-acquired infections for multiple other things, and we share that data nationally. This is built-in in a wide sense, and I think we at least have the testing platform, the sequencing and everything else along those lines, to make sure that’s a permanent thing. And that’s in place for the transition period.

Gurney: Who does this surveillance work? Like, is that WHO? Is that hospitals, local health units? Health Canada?

Chagla: Oh, in Canada, we are linked. Provincial and public-health authorities do this work; the data is shared. Traveller arrivals at airports are federally mandated so that data will come in. The sequencing work we do locally will feed into international data pools. Countries with the capacity upload into large global data-sharing networks. So we get a sense of what’s happening in the world. Incredible capacity has been built up to ensure that countries are able to report what’s happening. The international collaboration is there, and we have it locally, too.

Gurney: You’ve mentioned building capacity. What new capacity did we need? What did we build on the fly that we should keep? What do we still need more of?

Chagla: PCR testing is the gold standard, and we have a lot of it now in Ontario. A lot of it began coming online over, say, the last six months. We could do over 100,000 tests a day now. We could do aggressive testing now, very quickly. The actual physical infrastructure is now here in Ontario for us to do a lot of tests with a reasonable turnaround and without major barriers. Long-term, do we need to have testing centres in every region, in every city, in every part of the province so people can access it at any time of day and night? That’s a great capacity! But we can’t ignore that that’s a huge use of health-care resources and workers. We need those people dealing with patients, and it’s also very expensive. So there’s a blended model — we keep the testing centres but at a lower-capacity. You can still get the appointment, but not necessarily almost instantly.

The rapid-testing capacity is something we never really developed. We explored it in a few places. We had some successes at workplaces. But I think that’s going to be the future in the long-term history of COVID. More rapid testing. Schools could do rapid tests as part of their operation — a symptomatic child could get a rapid test. Workplaces, hospitals, even family doctors. If someone walks in with a cough, the doctor could do a rapid test on site to rule out COVID. People should be able to go to their primary-care doctor or a walk-in and get tested instead of going to a specialized testing site for a PCR. We should use these rapid tests to speed things up. Shorten isolation, shorten quarantine, get people back into school or work faster and safely. 

But long-term, here’s the thing: we can’t create a separate health-care system for people to access care for things that are COVID-related and keep another one for things that aren’t COVID-related. That’s even how we’ve been doing vaccines. But, long-term, your family doctor is much more able to integrate your runny nose and sore throat into your whole history — well, okay, your nose is runny, but you have allergies. Or, hmmm, you don’t normally get a cough like this — let’s get a COVID test. It’s not sustainable for the system to have these testing centres and vaccination centres long-term. That’s what we had to do now, during the emergency, but soon? We can stop doing this. And we will. 

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

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