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Why it’s becoming more difficult to navigate Canada’s conflicting COVID-19 guidelines

Christopher Ashby feels overwhelmed by the flood of messages every day from all levels of government. 

“Between nine o’clock in the morning and three o’clock in the afternoon, many decisions and many things have changed each and every day,” the Toronto hospitality worker told CBC News. 

“There’s so many messages coming through the course of the day between tweets and press conferences and what’s in printed press and what’s online — there’s just an avalanche of information.” 

With a member of his family who is immunocompromised, another who works in health care, a university student and an elementary school student, Ashby said he and his family struggled with what to do as Thanksgiving approached during the coronavirus pandemic.  

“Before the regulations had shifted and changed yet again, we as a family pretty much made the decision that Thanksgiving would be a pass this year,” he said.

“There were just way too many variables to feel comfortable.”

So instead of a large family gathering, he and his partner are opting for a quiet dinner together.

“We need to make what we feel is the right decision for us and we definitely err on the side of caution,” he said. “This is not something that people should be taking risks over because it affects too many people.” 

‘Different communities have different issues’

Depending where you live in Canada, it’s getting harder to navigate conflicting guidelines from various levels of government — because they can often seem completely out of sync.

“It’s up to Canadians throughout the country to do their part, to wear their mask, to maintain physical distancing,” Prime Minister Justin Trudeau said Monday. 

“Unfortunately, to not get together with their families and friends for Thanksgiving so that we can take control of this second wave, so that we can all celebrate at Christmas.”

Canadians are trying to decipher confusing advice from public health officials about what kind of gathering, if any, is appropriate and safe for Thanksgiving. 1:57

That advice is especially relevant to Ontario and Quebec, Canada’s Chief Public Health Officer said Monday. Daily case numbers and community transmission of COVID-19 in both provinces remain high, with strict public health restrictions on the number of people who can gather safely. 

“If you are in Ontario and Quebec, I think the most sensible thing to do is to keep to your immediate social circles,” Dr. Theresa Tam said. “Because you’ve seen the epidemic curve and this is not the time to be complacent about anything.” 

But social circles in Ontario haven’t been in place since Oct. 2, while Quebec’s hardest hit areas have banned visitors between households altogether.

“It is challenging for the public health authorities because the science and the circumstances are always changing,” said Timothy Caulfield, a Canada Research Chair in health law and policy at the University of Alberta.

“So that makes it more challenging to come up with a clear public health message. This isn’t like; wear your seatbelts, don’t smoke, eat fruits and vegetables, exercise — the situation is in flux.” 

Caulfield said confusion gets worse the higher you go, because federal officials need to speak on behalf of all Canadians — even in areas with very few cases like in the Atlantic bubble.

“Different communities have different issues,” he said. “So there is going to be variation from rural Alberta to downtown Toronto.”

Messaging in one area might not be relevant in another, but he said those messages can cut across the country, which “creates confusion.” 

Making sense of guidelines ‘incredibly challenging’

In Canada’s hardest hit provinces, the messaging is no less confusing.

Quebec moved to close bars, casinos, restaurants, libraries, museums and movie theatres in its hardest hit red zones this month, while also banning home gatherings as cases spiked

But the province also prohibited outdoor gatherings like barbecues, despite permitting people to meet in public spaces as long as they stayed two metres apart.

Quebec also recommends that people avoid leisure time with anyone outside their household, whether indoors or outdoors.

In Ontario, residents are being urged to avoid gathering with friends and family, but restaurants, bars, banquet halls and even casinos remain open with much higher limits on occupants.

“Having a large number of unmasked people in an indoor, closed, poorly ventilated space is how this spreads,” said Dr. David Fisman, epidemiology professor at the University of Toronto’s Dalla Lana School of Public Health. 

“So if you say, ‘Well, this only spreads when you’re with your family, it doesn’t spread when you’re with random strangers.’ It doesn’t make any sense.” 

Ontario Premier Doug Ford said Tuesday that making a comparison between the two types of gatherings was like comparing “apples and bananas.” 

“When you go into a restaurant they’re taking everyone’s name, they have six at a table, they have dividers, they have protocols in place, and the rest of the people in the restaurant you don’t know,” he said. “That’s the difference; at a family, you know the people.” 

Ontario Premier Doug Ford said Tuesday that making a comparison between gathering with family at home or going to a restaurant was like comparing “apples and bananas.” (Nathan Denette/The Canadian Press)

“Please, it’s very simple,” Ford continued. “There’s rules and there’s guidelines. The rules are very clear: 10 indoors, 25 outdoors. I would really, really discourage people from having 25 people even if it’s outdoors. Stick within 10 people.” 

Asked three separate times by reporters Tuesday to clarify whether he would visit with extended family on Thanksgiving, Ford first said he would only see 10 people, then said he would need to speak with his wife and follow up.

He later clarified on Twitter that he would only gather with those in his household.

“Sometimes the messaging isn’t as clear as it should be and it all comes down to communicating with each other better and I think we all need to do a better job — even myself included,” Ford said Wednesday.

“We have to just be a lot clearer, all levels of government and all chief medical officers, on the communication.”

Municipal officials in Ontario want provincial guidance

Local public health officials in Ontario have been vocal about the need for clearer messaging and more concrete action from the province after cases hit a record high last week. 

Toronto’s top doctor Eileen de Villa called for “immediate action” from the Ontario government Friday to stop the spread of COVID-19 as the city faces the risk of “exponential growth” of new infections.

She called on the province to instruct Toronto residents to leave their homes only for essential trips including work, education, health-care appointments and exercise and asked for an end to indoor dining in the city.

“If I had the power to do this, I would have done it,” she said. “It’s just this simple: I’m asking the province to do it or to give me the power to do it.”

In Ottawa, Medical Officer of Health Dr. Vera Etches called on residents to only get together with those in their immediate home for Thanksgiving and said even gathering outside was a bad idea

“My recommendation is to stick to your household,” she said. “Because we’ve seen examples where people gathered in a park and someone was sick and then more people got sick with COVID.” 

While Etches didn’t go as far as de Villa in calling for a ban on indoor dining in Ottawa, she did recommend people only eat out or go to a bar with those they live with.

Tam said public health officials in different parts of the country are trying to tailor their response to the realities of the situation on the ground. (Adrian Wyld/The Canadian Press)

Tam said Monday public health officials in different parts of the country are trying to tailor their response to the realities of the situation on the ground, which may account for some of the differing guidelines, but they are also “steering in uncertain waters.”

“No one knows exactly what is going to work,” she said. “So there’s a grey zone and people are doing slightly different things.” 

How can we blame individuals, when it’s incredibly challenging to make sense of any of the advice? – Dr. Andrew Boozary, executive director of health and social policy for Toronto’s University Health Network

“This just drives confusion en masse when you see such discord between different levels of government, between different public health units, between what’s being put out in the media, in press conferences,” said Dr. Andrew Boozary, executive director of health and social policy for Toronto’s University Health Network.

“How can we blame individuals, when it’s incredibly challenging to make sense of any of the advice?” 

Caulfield said public health officials and politicians need to be more transparent about the uncertainty they’re facing and the science informing health policies, because it signals to the public that the guidelines could change in the future. 

“Good public health communication is incredibly important, especially when it appears we’re getting some sense that trust is starting to wane and people are starting to get more frustrated,” he said. 

“It’s a really chaotic information environment right now, but we have to get it right.”

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‘Our safety is becoming secondary’: How funeral homes are grappling with mounting COVID-19 deaths

When the World Health Organization declared the coronavirus outbreak a pandemic back in early March, Bridget Fetterly had a plan to split the staff at her family-owned funeral home in Montreal into two teams. That way, if one team was required to isolate, the second team could step in and keep the business operating.

But as the death toll from COVID-19 began to rapidly rise, Fetterly realized she couldn’t afford to only have half of her staff at Kane & Fetterly funeral home working — she was going to need everyone. 

Funeral home workers are on the front lines of this pandemic, and like hospitals and grocery stores, they have had to make significant changes to their usual services. But despite having to go into high-risk zones, ration their personal protective equipment (PPE), and provide support to those who have lost loved ones in this unprecedented time, many funeral directors feel as though the role of their staff in helping manage the outbreak is overlooked.

“We’re sort of the people that no one wants to talk about because no one wants to deal with death,” said Fetterly. 

In fact, some parts of Canada didn’t consider them essential until two months ago.

“It took a pandemic for us to be considered essential services although we’ve always felt that we have been for a long time. It’s a little disheartening,” Ryan Crean, CEO and funeral director of Kearney Funeral Services in Vancouver, said of the situation in B.C. 

“We do put ourselves at risk to help families and make sure that people are looked after.”

Funeral home workers remove a body from the Verdun CHSLD seniors’ residence on April 15 in Montreal. (Ryan Remiorz/The Canadian Press)

More than 3,700 people have died from coronavirus in Canada in the past two months. While there are just over 1,500 funeral homes across the country, most of the deaths are concentrated in Ontario, Quebec, and British Columbia, leaving the funeral homes in those provinces to meet the demand of burying the bodies.

“We’ve been increasingly getting more and more and more calls,” said Fetterly, whose work days have extended far past a typical 9 a.m. to 5 p.m. shift.

She’s been getting so many calls that she now spends most of her evenings at the office just to get everything done and has had to scrap the two-team contingency plan and have all her staff working.

Now, Fetterly worries that if one staff member becomes infected with the virus, they all might be exposed in the office and will need to stay home to isolate. “Our safety is becoming secondary,” she said.

Transfer staff doubly exposed

Most of the deaths in Canada have occurred in hospitals and long-term care homes, which has meant transfer staff from funeral homes are going into high-risk zones. 

“We’re actually more concerned with the living, to be honest, than the deceased,” said Jimmy Cardinal, president of Cardinal Funeral Homes in Toronto. 

Given the threat of exposure to the virus in those COVID-19 hotspots, management teams at funeral homes have had to find ways to protect the health of their transfer personnel. Part of that has included a stringent uniform of personal protective equipment.

Transfer staff have also been limited to specific entryways at hospitals or long-term care homes when picking up bodies to reduce their risk of exposure.

WATCH | COVID-19: Is it safe to attend funeral?

An infectious disease specialist answers your questions about COVID-19, including whether it’s safe to attend a funeral. 2:39

Ontario has made an effort to take further steps. The province’s Office of the Chief Coroner has ordered funeral home personnel to hand over their stretchers to staff at hospitals and long-term care facilities and have them bring the dead outside. 

“It limits the spread from any of the staff from a funeral home going into a facility,” said Cardinal. 

The situation is different in other provinces. In B.C., Crean said he’s had a few facilities offer his staff this procedure, but it’s not the norm. 

Merely entering those buildings poses a threat to transfer personnel, and handling the bodies of individuals who tested positive for the coronavirus increases that risk. Given the emerging science on the transmission of the virus after death, funeral directors are taking extra precautions.

“We need to treat this like this is an incredibly infectious airborne pathogen,” said Crean. “So, we’re just going that extra mile to make sure that our staff are looked after.” 

Workers in Kirkland, Wash., in suits and respirators about to enter a nursing home at the center of the COVID-19 outbreak in the state. Ryan Crean, CEO and funeral director of Kearney Funeral Services in Vancouver, has also instructed his transfer personnel to wear respirators when retrieving deceased bodies from high-risk zones. (Ted S. Warren/The Associated Press)

In a routine pickup, transfer personnel would typically be required to only wear gloves, unless the body was a confirmed case of tuberculosis (TB), explained Crean. Now, with the coronavirus, he’s made sure his staff treat every case as if it was as infectious as TB, which means sending them out in full PPE — including gloves, masks, gowns, face shields and even N95 respirators. 

“Some people get a little scared,” Crean said. 

Based on the science currently available, experts believe the virus could possibly remain in or on the body of someone who has died from it. 

“It is still possible that someone who is touching or handling the body of someone who has died of or with COVID-19 can become infected,” said Dr. Ilan Schwartz, infectious diseases specialist and assistant professor at the University of Alberta. 

For comparison, experts have looked at the SARS outbreak in 2003, where some investigations suggest the virus could remain infectious in bodily fluids (blood, urine, and feces) for 72 to 96 hours.

“This doesn’t perfectly mimic what happens in a person, but it gives us some ideas on how stable coronaviruses are in different bodily fluids and may give some information on SARS-CoV-2, the causative agent of COVID-19,” said Dr. Jason Kindrachuk, a Canada research chair in emerging viruses at the University of Manitoba in Winnipeg.

PPE diverted

As in many industries, funeral businesses are facing obstacles acquiring PPE for their staff, despite efforts to supply the equipment to frontline workers.

“They’re giving them or selling them to hospitals and other health-care institutions first, so we’ve been trying to ration as much as we can,” said Cardinal.

WATCH | Navigating grief during COVID-19:

Our panel talks to Andrew Chang about how people can manage their grief, especially from the Nova Scotia shooting rampage, during the COVID-19 pandemic when people have been forced apart. 4:30

A month before the outbreak, he was already finding it difficult to obtain masks and gowns.

“We’ve been trying to buy as many as we can from our normal suppliers, but a lot of them obviously don’t have a lot of stock available,” Cardinal said.

In B.C., Crean says he hasn’t faced a shortage yet, thanks to orders made in January and February, but his latest replenishment was diverted to a hospital, and three weeks later, he’s still waiting to receive a new shipment. 

“We definitely do have trouble getting PPE,” he said.

When it comes time for organizing funeral services, most places have capped the number of attendees at 10 in order to comply with physical distancing measures. 

Most funeral services typically have many more attendees, Cardinal said, although allowing for 10 people “does give the ability for most immediate family members the opportunity to say goodbye.”

Cardinal and Fetterly said they have found many people are choosing to postpone funerals altogether.

“People just can’t do what they had hoped to do in the past,” said Cardinal. 

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Regulations, funding keep Canada from becoming world leader in cannabis research, scientists say

Onerous regulations and insufficient funding are holding back cannabis research in Canada, some experts say, a year after recreational use of the drug became legal.

“I’ll be honest, I’ve become very cynical over the past year,” said Lynda Balneaves, an associate professor at the University of Manitoba’s College of Nursing and deputy director of the Canadian Consortium for the Investigation of Cannabinoids.

“I think [regulations are] really preventing us from rapidly getting research conducted, and getting research evidence out to clinicians, to the general public, to policy-makers.

“I think we’ve actually created some very difficult procedures to get the research off the ground.”

Since the use and sale of recreational cannabis became legal in Canada on Oct. 17, 2018, Balneaves said she’s seen an explosion in the number of researchers seeking to study the drug, and increased federal spending.

But she says strict rules and delays at Health Canada have put barriers in the way of new projects, and funding from government and industry hasn’t kept up with booming interest — leaving some of Canada’s ample potential untapped.

Lynda Balneaves is an associate professor at the University of Manitoba’s College of Nursing and deputy director of the Canadian Consortium for the Investigation of Cannabinoids. (The Fifth Estate)

Scientists had high hopes for research possibilities opened up by legalization. Ottawa’s leader on the file, Organized Crime Reduction Minister Bill Blair, has said there’s a need for more research on the drug and the world is looking to Canada as a leader to do it.

“There is a lot of potential in Canada,” Balneaves said.

“But I think we need to be much more proactive in funding this area if we hope to be that world leader. Otherwise, we will be surpassed by other countries that are rapidly running down this road.”

A matter of accountability: researcher

The federal government’s framework to guide legalization called out the “significant gaps” in understanding cannabis use and impairment, and said further research is “needed urgently.”

Jenna Valleriani, a cannabis researcher and CEO of the National Institute for Cannabis Health and Education, said facilitating cannabis research in Canada is a matter of accountability.

“It’s great that we’re legalizing cannabis,” she said. “But I think what’s more important is that we’re actually seeing evidence and data to inform those policies.”

It’s ‘universally acknowledged’ that more cannabis research is needed, one expert says. Here, a lab manager displays marijuana leaf tissueand plant callus, which a plant would grow from, at a medical marijuana facility in Richmond, B.C., in a 2014 photo. (Darryl Dyck/Canadian Press)

Since legalization, scientists have spoken out about lengthy delays at Health Canada in processing applications from researchers to work with cannabis. Though cannabis possession is now legal, researchers must still apply for a permit under the Cannabis Act to study the plant’s recreational or medicinal uses.

Michelle St. Pierre, a PhD student in clinical psychology at the University of British Columbia, said she reached out to Health Canada in January with a question about her application. Four and a half months later, the agency responded by directing her to an online resource she’d already consulted.

St. Pierre, whose work earned her a prestigious Vanier Canada scholarship, said Health Canada’s approval process for cannabis research is less strict now that the drug is legal, but is still far more onerous that studying alcohol, for example.

That process included Health Canada asking her for documents, she said, that she had never been asked to prepare before.

She said it’s not clear to her why the cannabis process is so much more stringent.

“It was very, very complicated, and when I think about alcohol, this type of licence isn’t required at all,” she said. “I’m not really sure what else it would be, [other] than stigma.”

A spokesperson for Health Canada said the agency has heard those concerns, and introduced a suite of changes in July, including adding more resources for the team that reviews research applications, tweaking the review process for lower-risk projects (like ones that involve a small amount of cannabis) and publishing guidelines to help researchers make applications.

As of Oct. 4, the agency had issued 171 research licences — up from 71 in mid-July — and had 181 still in queue, the spokesperson said.

“It’s hard to overstate the consequences of these kinds of barriers in terms of slowing down and stopping research,” said James MacKillop, director of the Michael G. DeGroote Centre for Medicinal Cannabis Research at McMaster University.

“Appropriate researchers will not go forward without all the necessary compliance pieces being in place.”

Funding directed to harm reduction, not medicine

The licensing delays have meant a lack of the well-designed clinical trials MacKillop said are “universally acknowledged” to be needed.

“Fundamentally, without these kinds of licences, researchers can’t generate the kind of evidence that we all agree we need to have a safe and appropriate understanding of cannabis.”

MacKillop said his lab hasn’t had trouble accessing funds for its work, and praised Ottawa’s commitment to funding research.

CBC has contacted CIHR to find out how much money the federal government has provided for cannabis research in the past year, but had not received a reply by deadline.

While that federal funding is a good start, say Valleriani and Balneaves, it has been outpaced by a boom in researchers in the field. Where a “handful” of cannabis scientists were applying for grants five or six years ago, Valleriani says hundreds are now vying for funds.

As of Oct. 4, Health Canada had issued 171 research licences — up from 71 in mid-July — and had 181 still in queue, a spokesperson said in an email. (Blair Gable/Reuters)

“It equates to even less … funding available, because the competition is so, so high,” she said.

Despite legalization, Valleriani and Balneaves said they see the stigma of cannabis lingering in the way grants are distributed, with a focus on research into potential harms from the drug, such as addiction and mental health problems.

The CIHR’s Integrated Cannabis Research Strategy names “medical benefits” as one of its three key research streams, alongside “understanding harms” and “data standards.” But Balneaves said medical research hasn’t seen its share of funding.

“When you keep funding people that are only focused on substance use, you’re going to get messaging that’s going to focus on substance use,” Balneaves said — “not necessarily [research] saying, ‘How do we look at cannabis from an unbiased perspective, or from all sides?'”

Industry responsibility

Valleriani and other researchers described funding cannabis research as a shared responsibility between government and industry.

“These are folks that are going to eventually be making lots and lots of money,” Valleriani said. “[There’s a responsibility] to kind of give some of that back to research initiatives.”

She said she sees cannabis legalization as a chance for researchers to build a relationship with industry.

And in spite of challenges, Balneaves said overall, she still sees potential for success in Canada’s weed research landscape, as long as it’s balanced between medical and non-medical research.

“We just have to make sure … there’s access to the product, and we have to make sure that there’s funds available.”

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The science behind why vaping is becoming so popular in Canada

Vaping is quickly becoming a lot more popular with Canadians, despite what little is known of its long-term health effects.

Experts say part of the reason for the surge in use in such a short time is the evolution of the devices themselves.

“We used to say that cigarettes are the most effective way of consuming nicotine, but e-cigarettes have replaced them,” said Dr. Robert Schwartz, a senior scientist at Toronto’s Centre for Addiction and Mental Health (CAMH).

“They’re so small and discreet and these new devices don’t create the huge clouds that the previous devices did — people can use them anywhere, all the time.”

Newer devices such as Juul or Vype, which came to the Canadian market last fall, mimic the physical feeling of a cigarette on the throat and use what are known as “nicotine salts” to deliver higher concentrations of the drug to the brain — much in the same way that cigarettes do. 

“It used to be that if the nicotine concentration was too high, it would give you a harsh or aversive feeling on your throat,” says David Hammond, a public health professor at the University of Waterloo who researches vaping in youth. 

“Juul solved that. That’s why Juul is somewhere around half the market. That’s why most of the other major brands in Canada, including Vype and the smaller ones, have switched to nicotine salts.”

E-cigarettes themselves aren’t new, having been first introduced in Canada in 2004, according to the Heart and Stroke Foundation, but the chemistry behind the devices has changed dramatically in the past two years with new players on the market. 

Schwartz says before the use of nicotine salts in products like Juul, the highest nicotine concentrations commercially sold in Canada were typically upward of 20 milligrams per millilitre, which is the regulated limit in the European Union. 

The maximum amount of nicotine content allowed in e-cigarettes in Canada is currently 66 milligrams per millilitre, according to Health Canada. The Canadian Cancer Society says the highest amount used in Juul products is 59, and 57 in Vype.

Juul says one of its cartridges, or pods, has roughly the same amount of nicotine as a pack of 20 cigarettes.

“Once they solved the chemistry of palatable nicotine delivery, then all those others factors that were responsible for vaping becoming popular,” Hammond says. 

“You throw in tasty flavours and boom you have a wonderful little drug delivery device that sits in your pocket.” 

‘It’s very easy to get addicted’

Eva Egnatieva, 16, started using an e-cigarette two months ago and admits she doesn’t know exactly why. 

“My friends, they’re older than me and they’re all smoking this,” the Toronto high school student said while inhaling a Juul e-cigarette between classes. 

“I think when I’m nervous or I have some problem, I smoke it and I’m relaxed, not worried.” 

Egnatieva says that while she’s never smoked a cigarette, she started using an e-cigarette without nicotine at the age of 15. She says the first time she tried an e-cigarette with nicotine in it she hated it, but stuck with it. 

“I only smoke Juul,” she says. “I don’t like to smoke cigarettes because I hate the smell of cigarettes.” 

Egnatieva says she has little knowledge of the long-term health effects of using the device, but it doesn’t discourage her from using it and has no plans to quit.

Dylan Mendonca, a 24-year-old University of Toronto student, says he occasionally smoked cigarettes in social settings but used a Juul to successfully transition off both. 

“One thing I really liked about it was that it actually completely made me feel like cigarettes were gross,” he says, adding that he then began using the device every day. 

“It took me a couple of months to stop, I just stopped buying them. And then I just left the e-cigarette at home, ‘lost’ the e-cigarette … It’s very easy to get addicted.” 

Surge in popularity 

Hammond says the growing popularity of e-cigarettes in Canada is in part because of their use as a tool to quit smoking, but also because of their attractiveness to young people. 

“Juul has both made them more likely to help smokers quit, it’s also made them more likely to bring new non-smoking youth into the market,” he says.

“We need to make them available to adult smokers; we still have five million Canadians that smoke, but we’ve done a poor job at framing these products as something you use to quit smoking, rather than something you take to a party on Friday night when you’re 17.”

Juul opened its first retail store in Toronto this summer. (Albert Leung/CBC)

Hammond led a study published in the British Medical Journal last June, based on online surveys of Canadians aged 16 to 19 in 2017 and 2018, which found that the number of Canadian teens who said they had vaped in the last month had grown 74 per cent, from 8.4 per cent in 2017 to 14.6 per cent in 2018.

New data from the U.S. National Institute on Drug Abuse show a significant increase in teenagers in grades eight, 10 and 12 who say they have used an e-cigarette since 2018. One in 11 U.S. students in Grade 8 reported they had vaped in the past month in 2019, one in five in Grade 10 and one in four in Grade 12.

“What we’re seeing now is rapidly increasing rates of e-cigarette use in teens and young adults,” says Dr. Nicholas Chadi, a pediatrician at CHU Sainte-Justine in Montreal and addiction medicine specialist. 

“They’ve been very aggressively marketed in all sorts of forms — social media and big billboard ads — to target young people, even though companies will say the contrary. The marketing strategy has worked very well.” 

Health concerns 

On Wednesday, health officials in London, Ont., announced what’s believed to be the first case in Canada of a respiratory illness linked to vaping. The high-school-age individual used e-cigarettes daily, was initially on life-support, and is now recovering at home. 

While it’s not yet known what was in the cartridge, Health Canada says it’s concerned by reports of severe pulmonary illness as well as the increase in vaping reported among Canadian youth and it’s considering “additional measures” regarding the role of flavours, nicotine concentration and product design, and how all of that contributes to vaping’s appeal to youth and non-smokers.

Health officials revealed today an Ontario high school student was put on life support after using e-cigarettes daily. 2:03

Toronto Public Health reported Thursday they had also encountered a small number of patients in recent weeks who potentially had a vaping-related illness. 

The U.S. Centers for Disease Control and Prevention reported 530 confirmed and probable cases of lung injury related to e-cigarettes as of Sept. 17, including at least seven deaths. 

“This remains a relatively new phenomenon in our country so we’re still wrestling to understand the long-term health effects, but certainly the short-term are incredibly concerning,” says Terry Dean, president and CEO of the Canadian Lung Association. “We certainly cannot view them as harmless, because they’re not.” 

Dean says appropriate regulation, policy and education led to the curbing of tobacco consumption rates in Canada and he believes a similar approach should be taken as soon as possible with e-cigarettes and in particular where they’re accessible for youth. 

“If you’re not vaping today — don’t start. Blanket statement,” he said. “If you are vaping to help stop smoking, your end goal should be to stop vaping.”

Chadi says there has never been such a “rapid uptake” in the history of recorded substance use in teens, many of whom may not know how addictive they are and how much nicotine they contain.

“There is some research that shows for young people ages 25 and under with a brain that’s still changing, these devices are not an effective smoking cessation tool because you can get very hooked up to the nicotine that comes with it,” he says.

“Doctors, pediatricians, but also dentists, social workers and school nurses need to ask the right questions to teens to know if they’re using them, what they think about them and try to help.” 

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Women still becoming pregnant on acne drug Accutane despite birth defect warnings

It’s long been known that the highly effective acne medication isotretinoin — marketed as Accutane and Roaccutane —  is tied to the risk of severe birth defects. But even with a special program in place to prevent conception in women taking the drug, each year two to three hundred women in the U.S. become pregnant while taking it, a new study shows.

The program, dubbed iPLEDGE, which was started in 2006 by the U.S. Food and Drug Administration, requires women who want a prescription for isotretinoin to use birth control or promise to abstain from intercourse and to take a pregnancy test before starting the drug and every month thereafter.

While the program may have reduced the number of pregnancies in women who take the drug, the number hasn’t been reduced to zero, according to the study published in JAMA Dermatology.

“This drug is really life changing for those with severe acne that is resistant to everything else,” said study coauthor Dr. Arash Mostaghimi, an assistant professor of dermatology at Harvard Medical School and Brigham and Women’s Hospital. “Even those who have had very mild acne can think about how it impacted them. Imagine how impactful it would be if it was severe and caused permanent scarring. I think of this as an opportunity to study the situation and to think about how we can improve the delivery of this medication to patients in the safest way possible.”

To take a closer look at the impact of iPLEDGE, Mostaghimi and his colleagues combed through data from the FDA’s Adverse Event Reporting System, which collects information on adverse events that have been reported by health-care providers, consumers and manufacturers.

The researchers found reports of 6,740 pregnancies among women taking isotretinoin between 1997 and 2017, which peaked at 768 pregnancies in 2006 and then began to decline, plateauing in 2011 at 218 to 310 per year. Among women of childbearing age who were registered for iPLEDGE in 2006 and 2009 to 2010, the pregnancy rates ranged from 33 per 10,000 to 65 per 10,000.

Just 41 per cent of the reports included the woman’s age. Among those reports, the average age of the women who became pregnant was 24.6 years. Overall, women aged 20 to 29 accounted for the highest number of reported pregnancies (1,510), therapeutic abortions (317) and miscarriages (227).

Minimize unplanned pregnancies

Mostaghimi hopes the discussion about isotretinoin won’t scare people with severe acne away from the drug. “I’ve seen such an improvement on people’s lives,” he said.

It’s unlikely that the number of pregnancies among women who are taking in isotretinoin will ever drop all the way to zero, said Dr. Hyagriv Simhan, vice chair for obstetrics at the UPMC Magee-Womens Hospital in Pittsburgh.

“No system is perfect,” said Simhan who was not involved in the new research. “But building in decision-support so doctors prescribing this medication could ask the right questions would go a long way to minimizing the number of unplanned pregnancies. Contraception is not perfect. But I think we could use it a lot better than we are.”

Since Accutane can damage the head, face, heart, central nervous system and limbs of a fetus, the prescribing information in Canada requires written consent from the patient, two negative pregnancy tests before treatment and the use of two reliable methods of birth control for women of child-bearing age.

In 2016, Canadian researchers also concluded that despite the strict guidelines, there were many failures in preventing pregnancy. 

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Are low-priced drugs becoming an endangered species?

This is an excerpt from Second Opinion, a weekly roundup of eclectic and under-the-radar health and medical science news emailed to subscribers every Saturday morning. If you haven't subscribed yet, you can do that by clicking here.

A single phrase in a federal government report released last week made a dire prediction about the future of drug prices: "Lower-cost medicines may become the exception rather than the norm."

The long-term trends are alarming.– Douglas Clark, executive director, Patented Medicine Prices Review Board ( PMPRB )

That warning, in its dry bureaucratic language, was contained in a new report from Canada's drug price monitoring agency, the Patented Medicine Prices Review Board (PMPRB). The report explores the "market entry dynamics" of new drugs approved in 2016 and 2017 in Canada, the U.S. and the European Union.

"The long-term trends are alarming," said Douglas Clark, the PMPRB's executive director. "This is the nature of the pharmaceutical marketplace we now find ourselves in. It's dominated by these very high-cost drugs."

Over a 10-year period, the price of Canada's top-selling patented drugs has increased by 800 per cent, according to the PMPRB.

It wasn't always this way. Between 1995 and 2003, the prices of new drugs stayed relatively low, increasing by less than one per cent on average annually.

What changed? A combination of public policy and scientific discovery ushered in the era of high-priced specialty drugs. To encourage pharmaceutical companies to develop drugs for cancer and rare diseases, governments offered tax incentives, longer patent protection and quicker approval.

"Those strategies do work," said Steve Morgan, a health economist at the University of British Columbia. "There's no question that advances in biotechnology have driven part of the focus on specialized medicines, but also it's got to be recognized that policy has had an effect here."

Almost half of the new drugs released in 2016 and 2017 were "orphan" drugs aimed at treating rare diseases, with prices per patient approaching $ 1 million per year.

One new drug — Mepsevii, which treats Sly syndrome, a rare genetic disorder — is listed at $ 944,000 per year. Another is priced at $ 806,300 per year: Brineura, for Batten disease, a rare nervous system disorder. And a third — Spinraza, for spinal muscular atrophy — costs $ 708,000 for the first year and $ 345,000 every year after that.

Two others cost around $ 630,000 per year: Emicizumab, for hemophilia A, and Eteplirsen, for Duchenne muscular dystrophy. An additional six new drugs on the list come at a cost of more than $ 100,000 a year.

A few years ago, a million-dollar drug would make headlines. But those prices are old news these days.

"It's no longer something that catches people's breath because it is happening more often now," said Morgan.

A quarter of the new drugs were cancer therapies with an average price of almost $ 14,000 for a 28-day treatment.

Since 2006, there has been a 200 per cent increase in the number of new drugs in Canada with an annual average treatment cost of $ 10,000 or more. 

Most medicines that come to market do not represent a truly substantial improvement over existing treatments.– Steve Morgan, health economist, University of British Columbia

Are these new drugs worth the price? In some cases, probably not, according to the report.

"Of the new medicines assessed by the PMPRB [in 2016], none offered a notable therapeutic improvement over existing therapies," the report stated.

"Most medicines that come to market do not represent a truly substantial improvement over existing treatments," said Morgan.

And increasingly provinces are advised not to cover the drug unless the price comes down.

The report cites decisions by the Canadian Agency for Drugs and Technologies in Health (CADTH) suggesting that "most new medicines launched in Canada are not cost-effective at their submitted prices, and the vast majority of these medicines were approved on the condition that their price be reduced" — in some cases by more than 95 per cent.

Steve Morgan is a health economist and professor at UBC. (CBC)

Are there signs that the world is approaching peak drug prices?

In April, the World Health Organization will hold its second international fair pricing forum to grapple with the high cost of drugs. And on Tuesday, executives from seven major pharmaceutical companies will face questions about their high drug prices in front of the U.S. Senate finance committee.  

"Maybe we're beginning to see the cracking, beginning to see the point at which this pricing paradigm might fail, when you get to the point of having congressional hearings like they're having in the U.S.," said Morgan.

"And maybe these global dialogues that the World Health Organization is hosting are part of the sign that, in fact, everyone is now acknowledging that something is wrong and this is … not sustainable."

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The Self-Driving Industry Is Finally Becoming More Realistic

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Over the last decade, most of the buzz around self-driving has focused on the vision originally launched by Google (now Waymo) and later Tesla and others, of a Level 5 (fully, really, truly, autonomous no matter what) personal automobile that you could afford and blissfully relax in the back seat of from then on. You could even send it to fetch your children from school or tell it to wander around waiting for you or maybe even find itself a parking space. More recently, it has become clear that Level 5 personal autos are going to take much longer and be much harder to create, than the initial rosy projections. At CES 2019 last week, this was reinforced by the way vendors moved from pie-in-the-sky promises at previous CES shows to a much more step-by-step, practical approach this year.

Level 5 Is Getting Further Away, Not Closer

Last year, in particular, was chock full of warning signs and pullbacks for autonomous vehicle efforts. Most famously, a number of high-profile accidents (aka crashes) on the part of Uber and Tesla cars have called into question whether some of the companies involved actually know what they’re doing. Along with that, Waymo, the undisputed leader in progress towards Level 5, met its self-imposed deadline of a commercial robo-taxi launch in 2018 only with the very softest possible launch to a small number of testers in restricted environments with limited routes. Tesla pulled the “Full Self-Driving” option from its order page, citing that it was causing confusion (if you mean confusion that something you ordered years ago may never actually be available for your specific vehicle, I guess).

However, on the bright side, there have been some positive developments in the autonomous vehicle space that point to likely near-term use cases and winners. Three of these stood out to me.

Aptiv: There’s a Lot of Money to Be Made In Levels 2, 3, and 4

One problem for nearly everyone aiming to produce a Level 5 vehicle is that it’s a total money sink. Unless you are Google and essentially print profits, or Tesla and Uber, who seem to be able to raise whatever money they need so far, that makes it a very expensive proposition with no near-term payoff. But for industry-leading automotive supplier Aptiv (formerly Delphi) the march from Level 2 through Level 5 is simply the natural progression of its automotive electronics business. They have laid out an advanced architecture that they believe will pave the way for car companies to get started with the process by integrating various existing driver assistance systems and then progressively improving them over time.

Aptiv is well positioned to evolve the electronics architecture for vehicles to support future innovations

Aptiv is well positioned to evolve the electronics architecture for vehicles to support future innovations

As a compelling demonstration of how this is working, I got a test ride in one of the cars Aptiv has provided to the Lyft fleet in Las Vegas. The car itself was similar to the one they were using last year, but the system had been upgraded to provide improved functionality. For example, implementing RTK (Real-Time Kinematic GPS augmentation) has allowed the cars to locate themselves within 2.5 cm (instead of 10 cm). That makes the difference between not knowing and knowing whether a pedestrian is standing on the edge of the curb or in the crosswalk. Impressively, but not surprisingly, in the several mile test drive I took, no operator intervention was required. That included dodging buses, pedestrians, and making unprotected U-turns on a busy 6-lane street.

Nvidia also made a major move in this direction. Previously it had primarily touted how its high-end Pegasus computer was perfect for Level 5 projects. Perhaps realizing that any type of volume sales for Level 5 or even Level 4 are likely to be slow in coming, Nvidia launched a Level 2+ solution, DRIVE AutoPilot, based on the less-expensive Xavier SoC — aiming to capture the large and growing volume of vehicles that have various driver assist and automated safety systems.

Deere: “Hey, We Did Autonomous Before People Knew What It Was”

David Cardinal getting a lift in an automated John Deere tractorJohn Deere has been putting a variety of autonomous driving technologies into its tractors for around 15 years. We got to ride in the current version, and not only is the technology impressive, but it has a no-brainer use case. Many farmers spend 12-16 hours a day driving their tractors up and down rows of crops. Any mistake and plants are crushed. As our Deere test driver pointed out, this is like being told to drive your car down the white line on the edge of a road for a solid day and having it cost you $ 3 for every time you deviated. RTK and camera-enabled, Deere’s top-of-the-line tractors can do the job with 2.5 cm (1 inch) accuracy.

Deere has also implemented a clever “route memorization” feature. Because not all crop fields are nice, straight lines of crops, the driver can maneuver through their field once, and then the tractor can repeat the task when needed. This allows the farmer to perform other essential tasks, like controlling whatever farm implement is attached. If the right way to proceed is to move slightly to one side to avoid driving on top of previously planted seeds, for example, the route can also easily be nudged to one side or the other. We got to witness this for ourselves as the massive tractor we were riding in retraced our steps perfectly through a windy route.

There are many other similar use cases like large scale industrial facilities and mines. They have an immediate payback and are feasible with today’s technology. They just aren’t quite as attention-getting as the promise of personal self-driving cars.

Robo Taxis Are Happening, Just Not the Way We Thought

Nvidia's DRIVE AGX Xavier is a lower-cost alternative to Pegasus for use in assisted-driving solutionsA number of companies have pared down the Level 5 challenge to make it more tractable. Some are limiting their locations to easier to navigate areas, like Voyage’s effort based in retirement communities. Others are looking at applications that don’t involve moving humans, like grocery delivery robot company Nuro, which has teamed up with Kroger to pilot autonomous delivery. Finally, other companies like Aptiv (with Lyft) and Cruise (part of GM) are tackling the broader challenge of Level 4, but with some operational constraints. They’ve limited their vehicles to areas that are accurately mapped and monitored, and where they can get needed infrastructure updates. They also don’t have the same cost constraints, as fleet vehicles have much higher utilization, and can, therefore, be much more expensive, than typical personal vehicles. They can monitor their vehicles from an operation center, and intervene as needed — something an individual can’t do if they send a personal vehicle off on an errand.

Robotaxis also provide a window into the likely future for transportation. Most industry experts argue that by the time we get close to Level 5 most people will not own cars, but instead will simply subscribe to a “mobility service.” Obviously, driving enthusiasts and those who live in rural areas will be exceptions, but for anyone in a reasonably dense area who doesn’t relish doing their own driving, or simply want their own, specialized vehicle, they probably won’t own a car at all.

Not everyone agrees with this prognosis. Zoox, for example, believes it can design, build, and sell a Level 5 car itself, and in a lot less time than most of the rest think is possible. We’ll know soon enough.

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