Systematically omitting indoor air quality: sub-standard guidance for shelters, group homes and long-term care in Ontario during the COVID-19 pandemic

ABSTRACT

Public Health Ontario (PHO) is mandated by legislation to share scientific advice during infectious disease outbreaks and help reduce health inequities in Ontario, Canada. PHO was founded in part to address the failures of Ontario’s public health system during the 2003 outbreak of SARS-CoV-1, which included the failure to address airborne transmission. By January 2021, public health authorities had access to a body of literature suggesting SARS-CoV-2 was airborne, and had received urgent warnings from scientists. We set out to document how PHO responded to the likelihood – and, eventually, the certainty – of airborne transmission in the context of its guidance for congregate settings such as long-term care and shelters. In October 2021, we reviewed PHO’s public, written COVID-19 guidance for these settings, with a focus on indoor air quality (IAQ) measures that mitigate airborne transmission, such as ventilation. We identified 11 PHO documents for congregate settings. They contained no references to IAQ measures. We did, however, find references to IAQ measures in parallel documents for schools, summer camps, and clinical offices. Our findings demonstrate PHO omitted key infection prevention measures from its COVID-19 guidance for congregate settings, putting workers and residents at greater risk of exposure, illness and death, and exacerbating health inequities.

KEYWORDS:

• Public health
• COVID-19
• health equity
• congregate settings
• ventilation

Acknowledgements

Thank you to Jessica Demeria, Kimberly Devotta, Melissa Goldstein, and Kate Francombe-Pridham for generously sharing your knowledge and insight during early stages of this work. Thank you to Karissa Avignon for your thoughtful and painstaking review of our data. Thank you to Pearl Buhariwala for your invaluable contributions to this project. Thank you to Jo-Ann Osei-Twum, Paula Chidwick and Victoria Arrandale for helping us think through specific public health, bioethical, and citation questions related to this manuscript. Thank you to Graham Hudson for your insights into legislative questions relevant to this manuscript. Thank you to the anonymous peer-reviewers for your thoughtful reading of our work and your important questions and suggestions. Your input significantly influenced the final manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/09581596.2023.2262736.

Notes

1. While Canadian jurisdictions are often referred to as fixed and legitimate categories, they are the product of land theft from Indigenous nations and groups. Ownership and/or use by Canada is often asserted in contradiction to Canada’s own laws and treaty obligations, and the original agreements between Indigenous nations and groups and the British Crown. In addition, there are wide swathes of territory for which there are no treaties or agreements, and to which Canada has no claim at all. Finally, Canadian jurisdictions are not contiguous – the land labelled as Canada on most maps is not all under Canadian jurisdiction. It would be inaccurate to refer to settler jurisdictional names and boundaries in Canada without pointing to the fact that they are imposed, relatively recent and, in many cases, contested and in flux. We do not refer to jurisdictions such as Ontario to suggest these are fixed and inevitable categories. Rather, we explore the mandate and actions of PHO in the context of the current settler colonial matrix of governance that helps to determine the conditions under which many people in what is currently called Ontario work and live.

2. We note that in settings characterized by coercion, even ventilation and filtration can be used as mechanisms of surveillance and control when accompanied by certain types of indoor air quality monitoring. We emphasize, however, that indoor air quality measures can be implemented effectively without this type of monitoring using well-known and time-tested principles of ventilation and filtration.

3. For a recent history of long-term care in Ontario and the policies that impacted residents and workers during the COVID-19 pandemic, see Badone (2021).

4. At the time of the study, PHO defined congregate facilities on its website as, ‘ … facilities where people (most or all of whom are not related) live or stay overnight and use shared spaces (e.g. common sleeping areas, bathrooms, kitchens) including: Shelters; Group homes; Correctional facilities; Children or youth residential settings’ (Public Health Ontario, 2022). In most COVID-19 guidance, PHO draws a distinction between general congregate settings and long-term care. In some cases, long-term care homes are also listed as health care settings. In others, they are bundled with retirement homes. Finally, while much of the guidance for congregate settings is framed by PHO as applying to congregate settings generally (excluding long-term care), some documents state that they are not specifically developed for correctional facilities.

5. We refer to version dates of these publications as available and archived at the time of the study.

6. While our study concluded in October 2021, we periodically identified and archived relevant changes to documents in our sample up to May 2022. We continued to generally monitor documents in our sample until May 2023.

7. PHO’s public, written guidance specifically for long-term care homes and congregate settings excluded IAQ measures in October 2021. However, other public health and government agencies and ministries published guidance on IAQ measures and COVID-19 prior to that date. For example, the Public Health Agency of Canada published, ‘COVID-19: Guidance on indoor ventilation during the pandemic’, in January 2021 (PHAC, 2021a) and ‘Using ventilation and filtration to reduce aerosol transmission of COVID-19 in long-term care homes’ in April 2021 (PHAC, 2021b). As noted, PHO itself explored the use HVAC in reducing transmission of COVID-19 in March 2021 (PHO, 2021b).

8. Authors on this paper began informing people in leadership positions at PHO about these omissions in September 2021. (Email from A. Katz to Vice-President, Science and Population Health, PHO, B. Schwartz [who was one of several addressees from different organizations], Sept. 27, 2021; Email from A. Katz to Chief Health Protection and Emergency Preparedness Officer, PHO, J. Hopkins, Oct. 19, 2021; Email from A. Katz to Chief Health Protection and Emergency Preparedness Officer, Nov. 4, 2021; Email from P. O’Campo to Vice-President, Science and Population Health, PHO, Feb. 9, 2022.) As both email authors and addressees were public sector employees, relevant correspondence should be a matter of public record and should be available through Freedom of Information request as per Ontario’s Freedom of Information and Protection of Privacy Act.

Additional information

Funding

Financial support for this work was partially provided by the School of Cities, University of Toronto and the Canadian Institutes of Health Research [PCS 183463].