‘We aren’t just little islands’: Niagara’s top doctor on the province’s response to Omicron

TVO.org asks Mustafa Hirji about the new variant, the U.S. border, and why he thinks Ontario needs a province-wide approach
By Justin Chandler - Published on Dec 09, 2021
Mustafa Hirji says the Omicron variant is more likely to come from the U.S. than southern Africa. (Niagara Region Public Health/YouTube)



As politicians, scientists, and health officials work to determine the risk posed by the Omicron variant of COVID-19, Canada has implemented travel restrictions and testing requirements for foreign travelers not from the United States.

But according to Mustafa Hirji, Niagara’s acting medical officer of health, the seemingly more infectious variant is much more likely to come from the U.S. border than southern Africa.

Hirji, who has advocated for tighter restrictions and more consistent testing of travelers from the U.S., speaks with TVO.org about the challenges at the border and why he thinks Ontario needs province-wide measures to slow transmission.

TVO.org: How would you describe the COVID-19 situation in Niagara right now relative to the rest of the province?

Mustafa Hirji: We are sort of middle-of-the-pack in representing the average of what’s going on in Ontario. There are some areas of the province that are seeing huge growth in cases and we’re fortunately not seeing that. We’re also not in one of the areas that have very low numbers of cases. We are seeing a steady increase in cases which I think is [similar to] what the province is seeing as a whole with cases going up.

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I think that’s a reflection that we have much more openness in society. People have a lot of social contact. It’s cooler weather, people are moving indoors, and we’re heading to the holiday season where I think people are getting into a bit of a celebratory mood and maybe relaxing some of the diligence that they’ve practiced in the past. And I think that’s also just what’s happened after a while — people just can’t keep that up in the long-term. And unfortunately, that means we’re seeing cases start to go up.

I really do think that there needs to be some provincial action to address this. The cases aren’t going to magically turn around and start to go down. We’re seeing in countries in Europe and elsewhere that have been hit by the Omicron variant that their cases have just exploded, and I think we would be well served if we got our cases right now to a much more controlled level so we’re best prepared to deal with the Omicron variant when it arrives, because it definitely will come.

TVO.org: How do things here compare to just across the border in Niagara, New York?

Hirji: It’s a completely different world on the other side of the border. I haven’t looked at the numbers very recently but about 10 days ago, we are seeing on the order of about 20 times higher daily case numbers per population on the U.S. side of the border than on our side. They have not done nearly as much to control COVID-19 of late; I think it’s only recently that they reintroduced mask requirements. And their vaccination uptake is much lower than ours as well.

Unfortunately, I think the U.S. is an area where COVID-19 is spreading uncontrollably, and they’re definitely seeing infection as a result. I think that’s significant when it comes to the Omicron variant because the U.S. also doesn’t have very good surveillance of what’s going on or what are the different variants that might be circulating. I think it’s almost certain that there’s a significant amount of Omicron variant circulating in the U.S., which they are just not aware of.

Agenda segment, December 2, 2021: Debunking COVID-19 myths

TVO.org: What sort of infection prevention controls currently exist at the border?

Mustafa Hirji: The measures we have here are really the same as anywhere else. We don’t have any authority over the border, that’s federal jurisdiction, so whatever the federal government has put in place is what applies. The border reopened about a month ago and more recently, [the federal government lifted] a requirement to show a test to come back after a relatively short stay. There is, in many cases, not much actually happening when people cross the border. If you’re fully vaccinated, you can go across the border for a short trip, come back, and show your proof of vaccination through your ArriveCAN app, and that’s basically it.

Some people are being flagged for random testing, and it’s through that random testing where, in other parts of the country, we have found some of the Omicron variant cases — including that one U.S. traveler who tested positive here and it turned out to be the Omicron variant. They left before we got that test result, but I think that speaks to even something that the federal government probably should be doing: routinely requiring everyone to be tested when they come back across the border.

TVO.org: That partially answers my next question, which is: are the existing controls working?

Hirji: We’ve been seeing consistently cases linked to U.S. travel: sometimes Americans, sometimes Canadians traveling to the U.S., coming back and being diagnosed with COVID-19 here. So absolutely we are seeing infection spreading from the U.S. side over into Canada. I don’t really believe the measures are doing a whole lot to prevent much spread of infection. If someone is actively symptomatic, they’re probably not coming across the border. If someone is unvaccinated there is a quarantine requirement for them, so they would be prevented from coming across the border. But I think most of our risk is not really from them — it’s going to be from the people who are probably fully vaccinated, because overwhelmingly people who cross the border are going to be fully vaccinated. We know sadly, the vaccine is not 100 per cent effective. It absolutely reduces the risk a lot, but we have breakthrough cases, and if someone crosses the border and you have 20 times more COVID-19 around there, your risk is suddenly 20 times higher of getting COVID-19. So, it’s quite likely that people are going to catch it when they cross the border and bring it back here.

TVO.org: In June, you mentioned that you would like to see higher vaccination rates, lower case rates, and some assurance that there wasn’t a unique variant of the virus on one side before reopening the border. Do you think that we had achieved those benchmarks before we loosened restrictions?

Hirji: I would say we didn’t. You could maybe debate that perhaps we got to higher vaccination rates. I think in Canada we got to where we wanted to be. I wanted to see that about 83 per cent of the people who are eligible to be vaccinated were fully vaccinated. We were about there in Canada but the U.S. wasn’t, and they still aren’t anywhere near that. Case numbers have been quite high in the U.S., but they never had their cases under control.

Most recently with the lifting of the requirement to show a test result to come back onto the Canadian side — that was lifted after we learned about the Omicron variant. I don’t know if we had detected it in the U.S. yet, but I think we had good reason to believe the U.S. was unable to know if they had that variant or not. I think on all three counts, we hadn’t met those conditions.

Agenda segment, June 11, 2021: What mobility data reveals about COVID-19

TVO.org: The federal government instituted a suite of travel restrictions and testing requirements in response to Omicron, but the U.S. is exempt. What is the impact of that?

Hirji: It obviously means that we’re not going to stop much of the risk out there. The risk to us was probably never going to be significantly from southern Africa. We have some travel from there, but not a lot of travel. The Omicron variant cases in Canada have largely not been from people traveling from southern Africa. We had the first few cases which of course were from Nigeria, and I can’t remember exactly where all the other ones were. We’re seeing very high counts of the Omicron variant in Europe. That’s an area we have a lot more travel from, and there are really no restrictions to that travel. And the U.S., of course, is completely exempt from almost any requirements.

I think if we were going to do border measures, we almost need to do border measures to all countries, because that’s the only way you’re reasonably going to have a chance of keeping this variant out. We’ve seen the variant now in well over 50 countries the last time I checked.

TVO.org: Omicron was confirmed in Hamilton and more recently in Niagara. What do we know about the case in Niagara?

Hirji: We don’t actually know too much about the case in Niagara. Just to clarify, this is a traveler from the United States. The person was a U.S. resident who traveled to Niagara for a few days and then left. They were flagged for random testing when they came across the border and through that test, they tested positive for COVID 19. By the time we got that test result, they’d already left the country and returned to the United States. We did do some follow-up to figure out who they were around and where they had been while they were here. We’ll keep an eye on it to see if there’s any links to spread from that. 

Fortunately, the person didn’t really seem to socialize with anybody here on the Canadian side of the border. They were really socializing with the party they traveled with so we think that the risk is relatively low from this person spreading the Omicron variant here, but I think it illustrates the risk of possibly other travelers who were not randomly tested, who may have had a similar experience of coming across the border, bringing that variant.

TVO.org: So this person was flagged for random testing as they came in, and then while they were here the results were processing, and the results came back after they left?

Hirji: Yep, that’s exactly how that worked.

TVO.org: There’s a lot that we don’t know about Omicron, how do you assess the appropriate level of concern?

Hirji: First off, I’ll say that I think we definitely need to have some concern about this. I don’t think there’s any scenario where this is going to turn out to be not a concern. Is it a relatively smaller concern, or is this potentially a really serious concern? I think that’s what we’re going to hopefully be figuring out over the next couple of weeks as we start to get a bit more information.

The thing I feel most confident saying is that the transmissibility does seem to be increased. I think it’s very consistent. Every datapoint we’re seeing implies that there is much more transmissibility of this variant. There’s nothing really pointing in the other direction. We’re seeing countries in Europe where the numbers are exploding in terms of how much it’s spreading. In Gauteng in South Africa it went from being a minor number of cases to being almost 100 per cent of their cases in the span of only two to three weeks, which is huge. The Delta variant took two to three months to become dominant.

We don’t yet know about the severity, and I think we don’t yet know about how well the vaccine is going to work. It’s going to work to some extent, but how well it works, we don’t know. But just given how quickly this is spreading, let’s say it turns out to be maybe only 80 per cent as severe, and hypothetically the vaccine is going to work just as effectively. But if it’s spreading far faster, and it’s going to be infecting two or three times more people, that’s still going to mean we have far more people who are going to get severe illness. And that’s assuming a scenario where it’s less severe: perhaps it turns out to be more severe.

To me that speaks to where I started off, saying the province needs to take a serious look now at getting the COVID-19 situation in Ontario under control and in getting us into as good a situation as we can be before the Omicron variant arrives. Right now, we seem to be leading into a lot of risk and hoping that we’ll let the cases keep rising, and we’ll hope that we get kids vaccinated, and hope we’ll ride out the winter without things getting too bad, and it’ll hopefully all work out for us. I think that’s just not a tenable strategy when you have the Omicron variant on the horizon, potentially making things far worse.

Agenda segment, December 2, 2021: The evolution of masking

TVO.org: In lieu of tougher provincial action, you have instituted local public health restrictions. There’s now incoming rules for recreational facilities. Could you tell me a little bit about those and about why you think they’ll work to reduce infection?

Hirji: So, the only new one is the one we have on recreational facilities. It really seeks to do three things. We’ve seen a pattern of outbreaks in sports and recreational facilities, so we want to address that risk, stop those outbreaks, and particularly stop outbreaks that have seeded infections in schools and disrupted learning for many, many children in school — and caused at least one outbreak in a school as well.

We see change rooms and closed spaces like that which are not well ventilated and where aerosolized virus can really build up — we want to minimize use of those rooms. By decongesting spaces like change rooms and getting people in and out of change rooms more quickly we can minimize that risk.

Secondarily, we just want to tighten up some of the vaccination rules that already exist in these facilities. Most people who are 12 and older are already required to be vaccinated, either through provincial rules or through the rules that sports leagues have put in place. We’re just making sure that there is a consistent rule: if you’re 12 and up, you must be fully vaccinated to be in these facilities, no matter your role. We’re also requiring that staff be vaccinated or tested regularly to work in these facilities because it doesn’t make a lot of sense if everybody who is using the facilities needs to be vaccinated, but the staff don’t have to be vaccinated.

I think that’s a modest measure to address some of the spread we’re seeing, but I don’t think it’s likely going to be enough to completely turn the trends that we are seeing here. And again, I think we’re probably going to need action provincially because this is not just a local problem. It’s a provincial problem.

TVO.org: You told the St. Catharines Standard recently that you don’t have any plans to implement more new local restrictions, but you’ve not ruled that out. What is your threshold for taking more action?

Hirji: There are two scenarios where that would occur. The first one is that we see some sort of focal area of risk locally that we need to address. The measures that we’ve put in place historically in food premises or with these athletic facilities has really been a reflection of that kind of targeted risk where we can use targeted measures to address it.

The other scenario I see, though, is if our cases start to rise to be extremely high, similar to what we’ve seen in other parts of the province.

There doesn’t seem to be any provincial appetite to take action to try and address those and it’s really falling to the local level to start to implement some measures. Most recently, Public Health Sudbury and Districts put in place some additional measures, and that’s a pattern we’ve seen across many areas, particularly in northern Ontario, where we are seeing the highest growth of cases. If we start to see large numbers of cases here, and the province is not acting, we would be forced to do something.

TVO.org: If it seems the province is leaving decisions up to local officials, how does that affect your ability to implement measures?

Hirji: I wouldn’t say it affects our ability to do stuff per se. Technically, we have the legal powers that we would be able to put in measures in place. I think, though, it is politically sometimes more challenging when you do something locally and your neighbors haven’t done that same thing. I think it opens up a lot of criticism. We went through a year and a half of the pandemic where action was led by the province, and it was only fine-tuning done locally. And now we seem to have done this paradigm shift where the expectation is that big things are done locally, and the province is really going to take a back seat. There hasn’t really been a communication of that strategy change, so I think it strikes people as unusual. It’s been very difficult for the medical officers of health around the province who have had to take that action, to deal with the politics around it.

We’re not seeing that it’s a couple of places in the province where cases are rising and everybody else is good. The Ontario Science Table did their report the other day, it showed that in 80-plus per cent of health units across the province, they’re seeing cases go up. They had [Niagara] as one of the places where cases are going down, which is no longer the case, so I don’t even think that’s true. Basically, everywhere is seeing cases go up. This is a provincial problem. And I think having a patchwork of different rules across the province is not necessarily going to give us a consistent approach for how we deal with this, and it’s going to create a lot of confusion.

We also know that our cases here Niagara have often gone up when the GTA’s cases have gone up. We aren’t just little islands unto ourselves. We are deeply integrated with what happens around us.

Agenda segment, November 19, 2021: What's driving COVID-19 cases in Sault Ste. Marie?

TVO.org: I wanted to ask you a bit about the vaccine rollout. I’ve heard some concerns in the local Niagara media about the availability of third doses and I know you’ve warned people that public health would be focusing on the pediatric vaccines. How is public health working to balance that?

Hirji: Really what we’ve seen evolve here is that parents who want to get their children vaccinated are overwhelmingly coming to public health clinics. There’s a little bit of vaccination for children being done in pharmacies and in primary care, but overwhelmingly they’re coming to our public health clinics. That’s really meant that our pharmacies, because they’re not seeing very many children, are really doing most of the booster doses right now for adults. Lots of adults are going to them and close to probably 1,000 a day are getting vaccinated through that channel. That’s sort of been the way the balance has naturally worked out for right now.

Our goal is that as we start to see a slowdown in parents bringing children for vaccination, we will no longer need that capacity all focused on children and we’ll start to move it over to supporting vaccinations of older people with booster doses. But we’re trying to be mindful of the risk here. When we add the 50-year-olds into the mix, we’re going to have over 200,000 people who need to get doses of vaccines. That’s just not something that’s going to happen over a short period of time. So, who is the group that needs two doses the most? I would argue it is the five to 11 age group. Right now, they have no vaccine, they’ve not had the opportunity to be vaccinated, so they have no protection. They’re also the age group where we see the highest risk of spread right now in our community. I think vaccinating them needs to be our top priority because that’s where the risk is and right now.

TVO.org: What’s your message for people looking forward to getting together over the holidays?

Hirji: I think we need to be mindful that we are unfortunately heading into a holiday period that is going to be higher risk. Cases are higher now than they have been previously, and are trending upwards. We also have the spectre of the Omicron variant.

That being said, we’re a far cry from where we were a year ago and we also have vaccines that are protecting us. I think we need to approach the holiday season where we can do more than we did last year, but we need to be mindful that we’re not in a zero-risk scenario.

So, the first thing I’d say is holiday gatherings are certainly fine to have and you can have extended family and friends over, but there is a provincial rule that indoor gatherings can only be up to 25 people, so definitely keep your gathering to that. And I would strongly recommend that you have a gathering where everybody is fully vaccinated. When we see spread of infection right now, it’s overwhelmingly amongst people going about their private activities in life, where they are around unvaccinated people, who are at the highest risk of getting infected and highest risk of passing it on. So, having an event with fully vaccinated people is my very strong recommendation.

And if you’re going to have children at that gathering, I would very strongly recommend that you get them at least one dose of vaccine before your holiday gathering. Children right now have the highest risk of COVID-19. If you’re going to have that gathering where everybody’s fully vaccinated, except for the children, the children are going to be in a spot where if anybody brings infection, almost certainly the children are going to get sick. If we can get them a dose of vaccine, we’re going to absolutely give them a lot of protection.

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

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