How Montreal, not long ago the epicentre of the pandemic in Canada, avoided a disastrous 3rd wave

Late last year, Dr. Sarah-Amlie Mercure and her team at Montreal's public health departmentwatched with worry as more transmissible variants of the coronavirus were identified in other parts of the world.

She knew it was only a matter of time before they arrived in the city, which had already struggled through two brutal, deadly waves of COVID-19.

Quebec's first case of the B117 variant, first identified in the United Kingdom, was confirmed in the Eastern Townships on Dec. 29.

Given its ability to spread more easily, Mercure knew they would have to act more quickly than in the past to avoid another surge.

"We changed basically everything in how we do things," said Mercure, the department's associate medical chief of infectious disease prevention and control.

In an in-depth interview, Mercure detailed those changes and the lessons learned from the struggles of last fall and spring.

Several of Quebec's regions saw a spike in cases earlier this month, putting pressure on hospitals and leading to tighter restrictions, but the province's largest city has so far escaped the worst of the third wave.

Projections released Thursday by the province's public health institute, the INSPQ, suggest that if the existing measures are maintained and followed, there will be a continued low stable case count in Montreal throughMay, which will then gradually taper off.Hospitalizations will also go down as the vaccination campaign expands, the INSPQ said.

Mercure points to improvements in key areas: more rigorous contact tracing (a well-documented problem earlier in the pandemic),faster lab results to confirm variant cases, shutting down schools and workplaces more quickly when a variant is detected, and targeted vaccinations in hotspots.

"We were very, very proactive," she said. Mercure cautioned, though, that a spike in cases could still happen even though the third wave appears to be on the wane. All it takes, she said, would be "one or two superspreading events."

Dr. Olivier Drouin, apediatrician at Montreal's Sainte-Justine Hospital and a public health researcher, saidhe's hopeful the city and the province as a whole has learned from past mistakes.

"I think from crises we learn things that we should do and not do," he said.

"I think both the city being the epicentre of the first and second wave, and the province having been the worst off early in the pandemic, have adjusted their approach."

Drouin said other provinces, including neighbouring Ontario, didn't appear to heed the same lessons opening upjust as the threat became clear.

"It was a bit shocking for me to learn what was allowed in Ontario up to February," he said."We haven't seen that in Quebec for months.''

The 'suppression' strategy

In public health parlance, Mercure said, there are three ways to approach the pandemic: on one end of the spectrum is "mitigation" (flattening the COVID-19 curve to protect the health system, as Quebec tried to do early on) and on the other, "elimination," as in the case of New Zealand.

Somewhere in between is "suppression," which Mercure described as targeted, swift attacks on outbreaks, with a particular focus on variant cases.

"What you want to do is prevent as many cases as you can, because what you want is preventing deaths and hospital admissions, but just not for the sake of saving your health-care system," she said.

"It's really because you want to drive this epidemic as low as possible."

The public, she said, has been more accepting of these measures, given that the vaccine offers an end in sight.

The decision to return to an earlier 8 p.m. curfew was met with protest, but on the whole, she said, "people are still with us. They still agree and adhere to all the public health measures."

This week, the Quebec government announced the situation was stable enough to push back the curfew starting nextMonday to 9:30 p.m., a move Mercure welcomed as a positive step.

Some experts, including Drouin, believe the government could have waited a week or two longer, to get more of the public vaccinated and ensure they won't have to backtrack once again.

"The problem is that, it's going to get harder and harder to go back," Drouinsaid.

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Dr. Sarah-Amlie Mercure said they have had to act quickly to stop outbreaks, given the new variants of COVID-19.

Open, then closed

The Quebec government and Montreal's public health departmenthaven't always been in lockstep.

Dr. Mylne Drouin, Montreal's public health director and Mercure's boss, was visibly concerned in March when the province pushed the curfew back to 9:30 p.m., reopened gymsand allowed high-school students to return to class full-time.

"We have to keep measures extremely strict," shesaid at the time, warning that a third wave of the virus was all but inevitable.

Many of those measures were quickly undone, as it became clear the variants of COVID-19 were wreaking havoc outside the city, particularly in Quebec City, where a superspreading event at a gym resulted in hundreds of cases.

"We thought that it was too soon for relaxing these measures in the gym," Mercure said.

"They were not open for very long. And we did have outbreaks of the variants. It's just so easy to spread the virus in this kind of environment."

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Prativa Baral, an epidemiologist and doctoral candidate at the Johns Hopkins Bloomberg School of Public Health, was among the experts critical of the Quebec government's decision to reopen.

It clearly resulted, she says, in the spike in cases in the regions, whereas Montreal has managed to avoid that same fate by closing back up.

"In areas that are densely populated, the risk of outbreaks is much higher. So as difficult as it's been for Montreal in keeping these restrictions, it has likely helped Montreal very much during this third wave," she said.

Targeting hotspots

During the first wave, Montreal like other cities saw a clear trend: The virus was brought to Montreal by returning travellers then spread to low-income, racialized neighbourhoods.

In an attempt to avoid that same dynamic playing out again, officials moved quickly to vaccinate parents in a small pocket of the city's west end, where the B117 variant was detected in schools and the community.

They also vaccinated about 1,000 people experiencing homelessness.

The quantitative results in both cases haven't been released but Mercure says it's clear both decisions paid dividends.

"It really made a difference," she said.

"We know that when you concentrate on the people or areas where in many cases are detected, that's going to help for the transmission, that's for sure now."

In a briefing Wednesday, Mylne Drouin said that, overall, Montreal had succeeded in vaccinating 75 per cent of those 60 and over in much of the city in part by holding pop-up clinics in areas where the rate was initially lower.

She struck an upbeat tone in her remarks, saying "all our indicators are stable or even decreasing."

When asked why the city was faring so much better than Toronto, she focused on her city's own approach.

"We haven't changed our measures much since January," she said.

"We created our own luck of not having any superspreader event," before quickly adding, "it's a very fragile balance."