21 December 2020

An evidence-based Alert system #nlpoli


Communication remains the single biggest chronic failure of the province’s COVID-19 response.

As regular readers of these e-scribbles know, that means it is really a management problem.

Government officials have a hard time explaining things clearly because they do not have a clear idea of what they are doing. 

You can see this problem most clearly in the “Alert” system announced last spring.  Many countries, states, and even cities use alert systems like this for emergencies.  They are easy to understand – when they are properly put together – and all the people who need to act can know what to do, when to do it, and why they are doing it.

In the case of a pandemic alert system, people reading it should be able to see what types of restrictions went with what level of risk. There’s an internal logic to the system:  a low risk goes with very low restrictions or rules.

 In Newfoundland and Labrador, the Alert system fails all the basics of a functional Alert system. That’s because it was never intended to be a proper staged system for easing or increasing restrictions in responses to changes in the risk of COVID.  The Chief Medical Officer cobbled it together in response to a political demand. 

That’s why it came with an increase in restrictions, just like we got to wear masks – a higher level of restriction – just because the government created the regional “bubble” and among provinces with the same extremely low incidence of disease.

You can also see this in the way the CMO implemented the system, something SRBP has pointed out before. We changed alert levels at arbitrary times.  Changes are supposed to come in response to risk.  Remember, back in April, when it was obvious the number of cases was dropping and the risk was soon at zero, the health minister’s comment was that we needed to *increase* restrictions.

That’s just absurd.

And it is also confirmation the provincial alert system - like the government response - is not based on evidence.

That will become clear in a second but if you want to see the failure of the existing Alert system look at events last month when the number of local cases started into climb.

Three examples:

First, ordinary citizens could not tell if what happened would cause the Chief Medical Officer to increase the Alert level.

As a result – and second - in three communities, people panicked, kept their kids home from schools, and took arbitrary measures.

Third, when asked about moving from one alert level to the next, the Chief Medical Officer said she did not know what it would take. 

If you want to see what a proper alert system looks like, take a look at New Zealand.

Alert Level 1 in New Zealand is called “Prepare”.

It shows a Risk Assessment with three indicators:

  •           COVID-19 is uncontrolled overseas.
  •            Sporadic imported cases.
  •            Isolated local transmission could be occurring in New Zealand.

That’s pretty much the situation in Newfoundland and Labrador right now. 

And here are the rules or restrictions that go with that level:

  •          Border entry measures to minimise risk of importing COVID-19 cases.
  •          Intensive testing for COVID-19.
  •          Rapid contact tracing of any positive case.
  •          Self-isolation and quarantine required.
  •          Schools and workplaces open, and legally must operate safely.
  •          No restrictions on personal movement but people are encouraged to maintain a record of where they have been.
  •          No restrictions on gatherings but organisers encouraged to maintain records to enable contact tracing.
  •          Stay home if you’re sick, report flu-like symptoms.
  •          Wash and dry hands, cough into elbow, do not touch your face.
  •          No restrictions on domestic transport — avoid public transport or travel if sick.
  •          No restrictions on workplaces or services but they are encouraged to maintain records to enable contact tracing.
  •          QR codes issued by the NZ Government legally must be displayed in workplaces and on public transport to enable use of the NZ COVID Tracer app for contact tracing.

Here’s the indication for the next level, called “Reduce”.

  •            Limited community transmission could be occurring.
  •            Active clusters in more than 1 region.

We have no community transmission. Every case seen since May is a traveler or is, at most, no more than one person removed from a traveler. Calling them active clusters would be a stretch since they are contained so quickly and there is no or virtually no transmission beyond a single household. Use the World Health Organization definitions to see how international experts classify these things.

If we used the New Zealand system in Newfoundland and Labrador, we’d be at Alert Level 1.  No masks.  No restrictions on gathering sizes. No restrictions on work sites.

Compare that to what is going on here.

If you look at our level of restrictions and line it up with the New Zealand system, we’d be at Level 3.  That’s where you find recommended masks (we have mandatory masks), limitations on workplaces and gatherings.  There are some variations.  The New Zealand system makes a big jump between Level 2 and Level 3.  But if you consider how easily we have closed schools and post-secondary sites, and the restrictions on schools, we are arguably a more intense version of Level 3.

preventepidemics.org has a model system that is very similar to the one used in New Zealand.  Their website notes that “Alert-level systems provide a framework to support clear decision-making, improve accountability, and communicate with the public to increase healthy behavior change.”

“Risk alert-level systems communicate visually the level of health risk and indicate what measures should be taken at each level to maximize safety. In the highest alert stage, there may be lockdowns that require people to stay home and closures of schools, places of worship and nonessential businesses. As the level of alert is reduced, a stepwise lessening of these restrictions is possible.

When done well, risk alert-level systems promote transparency, accountability, and clear communication with the public.

Transparency: Data supporting each level of the risk alert system should be publicly available.

Accountability: Evidence-based guidance for each level allows governments, communities, and individuals to assume responsibility for their actions.

Clear communication with the public: Outlining behaviors for each level and giving the public advance notice of a change in level can improve protective actions.

Importance of clear risk communication

Risk communication can help achieve widespread behavior change necessary in crisis response, but it must be done well to be effective. If the public perceives a lack of consistency, competence, objectivity, empathy, sincerity, or transparency the result can be distrust and fear. Conversely, evidence suggests that when the public senses that a response has these positive characteristics, when information is easily understood and communicated through trusted and accessible channels, and when the necessary services are available, people are able to make informed choices, protect themselves, and heed recommended practices.

This site is worth checking out.  It includes a comparison of several alert systems, samples of public communication flyers, and a set of downloads that outline a comprehensive, rational alert system.  This is the first page of a nine-page model.

Even with the start of vaccine distribution, we are likely to be in some form of a COVID alert system for months or years to come.  The appearance of a new strain in England this past week raises the spectre of just such an eventuality.  

Politically,  it is attractive to herald the arrival of a vaccine as the beginning of the end. It wasn't D-Day.  Prudence would suggest that the start of vaccine distribution was closer to the Allied invasion of  North Africa and successes in the battle of Egypt against Erwin Rommel's Afrika Korps.

Winston Churchill said at the time:  “This is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”

That's why the provincial government would be well-advised to devote some time and resources to developing a proper alert system. We don't need more of the hysteria that has gripped communities like Deer Lake and Harbour Breton that sap health and other resources as a result. It is not fair to the people in those communities.  They and their children suffer.  Businesses suffer. Rotational workers suffer from the busy-bodies who have caused police investigations of more than 6,500 complaints with only five of them having some merit.  It is all avoidable.

Thrice-weekly dog and pony shows will not fix the problem. It requires nothing bigger or bolder than developing a coherent alert system based on evidence.