Demographics, distancing and dumb luck: How N.B. avoided a worst-case COVID-19 scenario

We're small, we're rural, we're old and we're spread out.

We lack a major metropolitan centre, large-scale public transit and international airline connections.

These are all traits that have been cited at one time or another as holding New Brunswick back. But they may be a blessing when it comes to COVID-19. 

"Luck is a big part of it," said Dr. Raywat Deonandan, an epidemiologist at the University of Ottawa.

"You're lucky in your location, you're lucky in your population density, you're lucky in your population distribution, and you're lucky that your major city is not an international travel hub."

If the numbers over the past two weeks hold, New Brunswick — a province that rarely wins at anything — is poised to reach the pandemic-containment podium.

New daily cases peaked at 15 on March 29. By the second week of April, there were more recovered patients than people still sick with the virus. And there hasn't been a new case reported since April 17.  

As of Sunday's update, only seven New Brunswick cases were listed as active. Only Nunavut and the Northwest Territories have lower rates of cases per capita.

Colin Furness, a professor and expert in public health information at the University of Toronto, said the province's success is clear, but it's not due to demographics alone.

"It really is good luck, good planning, good execution," he said. "The measures taken by the government to do social distancing were the right measures."

Here's a look at several of the factors that seem to have contributed to New Brunswick emerging relatively unscathed from the first wave of the COVID-19 pandemic.

Lack of urban density

New Brunswick was never going to be the ideal breeding ground for the coronavirus. The province is more rural than most and lacks a single large metropolis. 

Population density in Moncton and Saint John hover around 1,000 people per square kilometre. Compare that to Montreal, where it's 2,700 people. In Wuhan, China, and Milan, Italy, it's more than 7,000.

"Jurisdictions that have higher density, it can influence it for sure," said Dr. Jennifer Russell, the chief medical officer of health "I don't have a specific ability to quantify that but it definitely does have an effect." 

COVID-19 needs "pretty intimate contact" to spread, Furness said. "People need to be close together."

There's an emerging consensus from researchers that the longer and closer someone is exposed to COVID-19, the greater chance they'll catch it and the worse the symptoms may be.

That's more likely in large centres where there are lots of apartment buildings with thousands of residents each, and busy public transit systems full of commuters jammed together.

"The population density is not amenable to rapid spread in New Brunswick," Deonandan said. "So you got lucky in that sense."

No major air hub

Connected to the lack of dense metropolitan centres is the absence of a major international airport.

"You're not getting as many travellers coming from high-risk parts of the world," Deonandan said.

New Brunswick's three largest cities have jockeyed for years to persuade airlines to add more routes, with some success. 

But the numbers are still tiny.

The Greater Moncton Roméo LeBlanc International Airport reported 680,000 passengers in 2018. Trudeau International Airport in Montreal had 19.4 million and JFK in New York City had 61 million.

"When you see the worst cases, it's almost always close to where they have a lot of travel," Furness said. 

A minister with foresight

One possible turning point in New Brunswick's containment effort was Feb. 24, when Education Minister Dominic Cardy sent an internal memo to senior government officials sounding the alarm that COVID-19 was on its way, if it wasn't already here. 

"This is not a question of if, but when," Cardy wrote. "The extent of the damage and disruption cannot yet be predicted, but it will occur."

With footnotes, appendices and hyperlinks, "memo" isn't quite the right word for the 19-page document, which was obtained by CBC News. It reads more like a university term paper.

Cardy's own department was already laying the groundwork for the closure of schools, but he went further in the memo, sketching what each level of government was responsible for, how each provincial department might respond, and which laws applied.

Many measures he suggested were later adopted by the Blaine Higgs government, including a special cabinet committee including the leaders of New Brunswick's three opposition parties.

"All governments will struggle to maintain legitimacy and confidence in the face of the pandemic," Cardy wrote. "Sharing a plan to address COVID-19, being honest about the risks and realistic in terms of a response, is essential." 

Cardy "put us on a learning curve which gave us a tremendous advantage," Health Minister Ted Flemming said in an interview. "Some of us might have been a little sceptical at the start. … He really was the spearhead. He was the leader on it." 

An early move in schools

Cardy's next move, controversial at the time but prescient in retrospect, was to ban any student who'd been on a March break trip outside Canada from returning to school.

"That was extremely wise, extremely prudent," Furness said. "Children mixing in schools is a really potent way for infections to spread."

Deonandan agreed: "The elephant in the room is kids in schools, because kids get their hands in everything." 

Furness said he can "guarantee" some children came back from the break carrying COVID-19 but not showing symptoms. If they'd gone to school, the virus might have spread to classmates, and then to more vulnerable adults, in large numbers.

"That obviously didn't happen, so you got away with it," he said. "Our success is predicated on things that don't happen. We can never know. But I think your education minister is to be congratulated."

Jumping on the early cases

The first trickle of cases into the province, which began showing up March 11, was small enough and manageable enough that public health measures were able to keep them under control.

"It definitely was helped by the fact that we had measures in place very early on around informing people that they had to self-isolate when coming from outside the country, and then … when they came from outside the province," Russell said.

The first batch of New Brunswick cases were people who had travelled to France, the United Kingdom, the United States, the Caribbean and on cruise ships. 

Testing those people and getting them to self-isolate, and then quickly tracing any contacts they had, was key, as was the closure of schools and businesses and the banning of mass gatherings, Russell said.

"This all had an effect on being able to contain those early travel-related cases for sure, because it limited the number of contacts that each person had." 

The result is only 10 community transmission cases until now.

No nursing home outbreaks

That in turn reduced the chances of someone with COVID-19 unwittingly bringing the virus into a nursing home or special-care home full of seniors. 

One employee of a Shannex nursing home in Quispamsis tested positive for the virus in early April, but there has been no major outbreak. 

Compare that to neighbouring provinces: as of Sunday, 249 of Nova Scotia's 873 cases were residents or employees of Northwood, a long-term care facility in Halifax. Of the province's 24 deaths, 18 have been Northwood residents.

In Quebec, more than 20 per cent of all COVID-19 cases, and a staggering 80 per cent of all COVID-19 deaths, have been in seniors residences.

Tony Weeks, CEO of York Care Centre in Fredericton, said his facility decided early on to stay ahead of the virus, ensuring that employees working in multiple residences limited themselves to only one to reduce the chance of spread.

"We haven't waited for a first case to show up," Weeks said. "We've planned as if that first case was here."

Vulnerable seniors are also spread out — and engaged

New Brunswick has the second-oldest population in Canada, and seniors are the most susceptible to serious and even fatal cases of COVID-19.

Yet other characteristics of that greying demographic mitigated the risk, the experts say.

The densest areas of the province are also the youngest. The places that skew oldest also happen to be more rural and more spread out from each other. Except in nursing and special-care homes, seniors tend to be farther away from each other.

"That's a protective effect," Deonandan said.

And Furness said older people are also paying the closest attention to coverage of the pandemic. They're engaged and informed.

"I get the smartest questions and the most careful, mindful questions from older people, questions like 'How do I handle my mail?'" he said. "People who are thinking that way aren't going to get sick. With age comes wisdom, and wisdom is a very potent protector."

Choosing to comply

Another obvious factor is that New Brunswickers have not defied recommendations on handwashing, physical distancing and other ways to avoid risk.

"People did have choices that they could make," Russell said. "The higher number of people in the population that makes wise choices … the better off we all are. It only takes a few people to impact the population as a whole."

"There's something to be said for the compliant population that followed orders and stayed home when they were supposed to stay home," Deonandan said. "You can't underestimate the power of that." 

Pure luck

And then there's the intangible factor: dumb luck.

In St. John's, one person with the virus but no symptoms visited Caul's Funeral Home in mid-March and became the so-called "index case" for at least 176 people who had contracted COVID-19 by April 8.

That's more than two-thirds of the province's 258 cases to date. Without that one index case, Newfoundland and Labrador's case numbers would be lower than here.

"New Brunswick didn't get unlucky by getting a whole bunch of virus [at] a super-spreading event, where one person attended an event and infected 30 others," Deodandan said. "You didn't get that kind of early boost to the virus that makes it so hard to control."  

The next phase

Russell said the next phase, a gradual reopening of the economy and society, will shed even more light on what works and what doesn't. 

She has said that there could be a cycle of loosening and then reimposing restrictions if the virus flares up. Some of the factors that kept numbers down could reduce the risk of new outbreaks as measures are lifted.

"It will be very interesting to see how all of those things contribute to the numbers moving forward and what kind of resurgence we might see," she says.