Michelle Gamage

New opioid prescription guidelines aim to reduce opioid-related harms IN LATE NOVEMBER 2023, the BC Centre on Substance Use published a new set of guidelines, replacing the previous clinical guidelines from 2017. The 2017 guidelines were published around a year after a public health emergency was declared in 2016 in response to a sharp increase in toxic drug deaths. A lot has changed since then, including an increase in research on opioid agonist treatment, or OAT, and what does and doesn’t work for patients, said Dr. Paxton Bach, an addiction medicine physician and co-chair of the guideline writing committee. The toxicity and unpredictability of the toxic drug supply has also increased. According to the BC Coroners Service, 1,495 people died from unregulated drugs in 2017. As of just September, 1,836 people have died so far this year. This update will hopefully make more people interested in starting opioid agonist therapy, Bach said. “OAT is the gold standard for the single most effective treatment for reducing non-prescribed opioid use, overdoses and mortality,” he added. The BCCSU defines opioid agonist treatment as prescription opioids that reduce opioid-related harms, reduce how often a person uses opioids sourced illicitly, and improve their mental health, social functioning and quality of life. In B.C., OAT includes opioids taken orally, such as Suboxone, methadone and Kadian. As of Wednesday, OAT also includes extended-release buprenorphine, which people can get as an injection at a pharmacy once every four to six weeks. It is estimated that 100,000 people in B.C. have opioid use disorder and around one-quarter of them are already on some form of opioid agonist therapy, Bach said. That means there are 75,000 more people in the province who could benefit from this therapy but haven’t yet tried it or stayed on it. Bach said one of the biggest changes is how the new guideline allows for more flexibility around missed doses and take-home doses, which he said patients had reported as the top reasons why they didn’t stay on OAT. These are powerful opioids and if patients get sick or are away and miss several doses, there is a risk that they will have lost some drug tolerance, he said. “We want to ensure the medication doesn’t put anyone at risk but we also know decreasing a dose unnecessarily can be destabilizing for a patient and can make people stop taking OAT entirely,” he said. The new guidelines work to balance the risk of patient destabilization and the risk of patient safety, he added. They also relax the rules around when a patient can take extra doses of OAT home with them. As these medications are highly regulated, most people need to go to a pharmacy every day to get their prescription, which they consume on-site, supervised by a pharmacist, Bach said. “This is a huge barrier for patients and an enormous cost on our system. In total, requiring [patients] to go to the pharmacy daily costs B.C. around $30 million per year,” he said. Daily pharmacy visits are that much more taxing for people in remote or rural communities, said Jess Lamb, co-founder and project co-ordinator of the East Kootenay Network of People Who Use Drugs. If a patient lives an hour away from their pharmacy, they have to drive 14 hours in a week to get vital medication, she said — and the cost of gas isn’t cheap. The new guidelines allow patients to access take-home doses more quickly than before, and call for a more collaborative decision-making process around what medications a patient will be on. Previously, it was recommended that a doctor first prescribe a patient Suboxone and, if it didn’t work, that they try prescribing methadone and Kadian as a final option. That was taxing for patients, so now they will be able to talk with their doctor about the effects of different medications and work out what would best help them right away, Bach said. The dosing recommendations for each medication have also been increased to better match the potency of the illicit street supply, Bach said. This is an important update, Lamb said. She personally has had to spend a lot of time advocating for the medication and dose she wanted from her OAT and safer supply to avoid getting sick. This update could help people avoid a situation like hers in the future, she said. Lamb celebrated the updated guidelines. But she added she was concerned that not all clinicians will read or respect these updates and patients will still have to fight with their primary care provider to get the medication they need through OAT. Guy Felicella, a peer clinical adviser with the BCCSU, also applauded the updates. “These new guidelines will make treatment more appealing,” he said. Felicella said he tried OAT back when he used drugs. The dose then was so low that it was laughable, he said. Empowering patients to ask for and get the medication they need at the dose they need will go a long way to helping patients want to try OAT and stay on it, he said. Hannah Dempsey, project co-ordinator with the BC Association of People on Opiate Maintenance, said she’s waiting to pass judgment until she can read through the entirety of the new guideline, which is 258 pages long. The association has been advocating for patients to have more access to take-home doses and to not have to take urine tests to stay in the program, which she said are degrading and stigmatizing. She also echoed Lamb’s concern that physicians will be able to interpret guidelines however they want to. “Guidelines are not policy,” she said. To stop overdoses during the toxic drug crisis requires many different harm reduction initiatives, like investment in safe consumption sites, take-home naloxone kits, meaningful access to a regulated supply of drugs and a significant overhaul of the current addiction treatment system, Bach said. More work needs to be done to address the reasons people use drugs, too, such as homelessness, poverty, mental illness and racism, he added. All of that is beyond the scope of clinical guidelines for doctors, however, he said. Michelle Gamage is a Local Journalism Initiative reporter with The Tyee.

Elizabeth May fell ill at an event on June 29, but didn’t get proper medical care until July 5, and didn’t find out she’d had a stroke until after Aug. 5. ELIZABETH MAY was standing on the University of Victoria auditorium stage on June 29, congratulating a recent high school graduate, when a “sudden, unbearable, excruciating pain” hit her, like someone had “hit the side of my head with a two-by-four.” “It felt like my head was going to split in two,” said the leader of the Green Party of Canada. May’s assistant helped get her home and gave her some Tylenol, worried she might be experiencing a migraine. The pain was so bad, May said, she couldn’t see straight. She was “violently ill,” so she took a COVID test, which was negative, and went to bed and slept for 24 hours. She’d been working 51 days in a row, often churning through 19-hour days leading up to Parliament’s summer recess. At first, her husband thought she was just exhausted. It would be six days before May saw a doctor, and not until she was discharged from hospital that she learned she’d had a hemorrhagic stroke. A hemorrhagic stroke occurs when an artery bleeds or bursts in your brain. It is less common than an ischemic stroke, which occurs when a blood clot restricts blood flow to the brain. May, who is 69, hasn’t had a family doctor since her last doctor retired eight years ago. It used to be that when a doctor retired, they’d refer you to a new physician, she said. Now you sit on a wait-list, as she and her husband have for the last five years, and hope you can be connected with a new family doctor. Around one million British Columbians don’t have a family doctor. Being a federal party leader doesn’t offer a “fast track” when it comes to public health, May said. “I have to wait like everyone else.” Because she hasn’t had a doctor for so long, May said, she doesn’t know what caused her stroke or if there were warning signs. May said she now knows she has extremely high blood pressure, but she doesn’t know if that caused the stroke or is a result of it. After May had slept for several days and was still experiencing impaired vision, her husband called 811 to speak with a nurse, who connected them with a doctor over the phone. The doctor recommended they go to Victoria General Hospital and said he’d call ahead so they could skip the emergency room lineup. But when they arrived no one was expecting them, and after five hours in the waiting room, May asked her husband to take her back home so she could sleep. A friend then recommended booking a walk-in appointment at a Shoreline Medical Society clinic. When May finally met with a doctor there on July 5, they sent her directly to Saanich Peninsula Hospital, where she was immediately admitted. She was discharged July 9 and got an MRI on Aug. 5. The MRI confirmed she’d had a hemorrhagic stroke. “There was a fair bit of time of not knowing,” May said. The doctor she met at Shoreline Medical has become her family doctor, May said. “He called me and said, ‘You need to know how lucky you are. You could have died but you didn’t. It doesn’t look like there’s any damage; you just need to rest and recover,’” she said. May said she doesn’t seem to be suffering from any lasting effects of the stroke, reporting her mood, health, energy and physical and mental well-being to be high. It shouldn’t take having a stroke to get a family doctor in Canada, May said. Her husband, John, who is 76, still doesn’t have a family doctor. May’s ideas on how to fix public health May has some ideas for how to fix public health so other Canadians don’t have to go through the same thing she did. She’d like to see a nurse’s station established at Parliament to check the blood pressure and vitals of MPs as they work long, stressful hours with little sleep. At the federal level, she’d like to see the government ask for “accountability” about how provinces and territories spend their Canada Health Transfer payments. May points to a Globe and Mail column by Andrew Coyne in which he calculated that federal transfer payments rose by 50 per cent per capita, after inflation, over the past two decades, while hospital wait times increased by 50 per cent over the same period. Money provided by the federal government for health care doesn’t have to get spent on health care, May said, adding the money is occasionally spent on tax cuts, for example. This is a critique repeated in Coyne’s column. She’d also like to see the federal government crack down on private health-care services. “Walmart, Telus telehealth — anything that offers health care to Canadians for money is a threat to public health that shouldn’t be allowed,” May said. When contacted to respond to these critiques, Mark Johnson, a spokesperson for Health Canada and the Public Health Agency of Canada, said provinces and territories are already required to report on their health care under the Canada Health Act Extra-billing and User Charges Information Regulations. Provinces and territories are also required to meet criteria and conditions for hospital and physician services under the Canada Health Act to get their “full” Canada Health Transfer funding, he said. The federal government’s role in health care is one of support more than management, Johnson added. But work is being done across the country to increase the number of training seats for physicians, nurse practitioners and nurses, including adding new medical schools at Simon Fraser University, Toronto Metropolitan University and the University of Prince Edward Island. Johnson said that last month federal, provincial and territorial ministers of health and mental health and addictions met in Prince Edward Island and committed to a study looking at how to meet future health-care demands over the next decade. At the provincial level, May said she’d like to reduce bureaucratic spending and increase investments to bolster the local health-care workforce. A lack of residencies and funding for training hospitals means young Canadian doctors are having to go to school or work internationally because there are no jobs for them here, she said. B.C. Health Minister Adrian Dix pushed back against that claim. Right now 80 per cent of B.C.’s medical graduates stay in the province, he said, compared with Alberta, which holds on to 60 per cent of its graduates. Around 20 per cent of medical graduates from Alberta come to practise in B.C., and around eight per cent of B.C. graduates go to Alberta. B.C. is also making “significant” changes to “the ways we pay physicians, train and retain them,” Dix said. Over the past five years, Dix said, the University of British Columbia has added 60 new postgraduate medical education positions in family medicine, cancer, surgery, maternity, seniors care and mental health and addiction, and this year it is adding 30 new positions for family medicine and 40 new undergraduate medical school seats. By 2028 there will be 48 new postgraduate medical education residency positions, he added. The new Simon Fraser University medical school in Surrey expects to be accepting students by 2026, he said. B.C. has also been working to increase how much it pays doctors. On a personal level, May said she’s going to start taking breaks when she’s tired, rather than trying to push through fatigue. “Going forward, I can still be the hardest-working MP without putting my life at risk,” she said. Michelle Gamage, Local Journalism Initiative Reporter

Deaths continue to mount from toxicity in BC's illicit drug supply. Are current policies helping? DR. BONNIE HENRY met with local government representatives from across the province in September to talk about decriminalization and to call for all levels of government to continue to fight against stigma when it comes to the ongoing toxic drug crisis. Stigma pushes people to use alone or without harm reduction services which can lead to fatal overdoses, and criminalization disproportionately impacts racialized people who use drugs, she said. Henry was speaking at the first day of the annual general meeting of the Union of BC Municipalities. “This is not a criminal or moral issue. It is a health and public health issue,” Henry said. “Decriminalization is part of what is needed to stem the tide of deaths.” As of July 2023, 12,739 people have died from toxic drug poisonings in B.C. since the public health emergency was declared in April 2016, with 1,455 dying so far this year, according to the BC Coroners Service. Henry also said decriminalization is a “pilot and is not perfect.” Decriminalization, which launched in January 2023, allows people 18 years and older to possess up to a combined 2.5 grams of opioids, crack and powder cocaine, meth and MDMA without risk of arrest, criminal charges or confiscation. The pilot will run until Jan. 31, 2026. Decriminalization isn’t legalization, Henry stressed, meaning stores are not allowed to sell these drugs and police can still arrest a person suspected of trafficking. On Monday, the Province’s decriminalization policy was amended to prohibit possession of illicit drugs within 15 metres of a playground, spray pool, wading pool or skate park. Karen Ward, a drug policy analyst and advocate who was not at the Union of BC Municipalities meeting, is deeply critical of the provincial attempt at “so-called decriminalization” and said these amendments feed into stigma against people who use drugs. “Who uses drugs in a wading pool? It’s ridiculous,” said Ward. People only use drugs in public places if there is no safe indoor place to do so, like an overdose prevention site, and because they want to make sure if they overdose someone will see them and be able to help, she added. “Decriminalization needs to involve a reallocation of funds that is currently spent criminalizing people and instead spend it on housing, funding overdose prevention sites, health care and social programs that prevent people from using drugs in the first place,” Ward said. When people complain about decriminalization they’re often confusing drug use, crime, poverty and homelessness, she added. “Living outside is terrible and awful and people use drugs to cope — it’s a consequence, not a cause,” she said. “Decriminalization is not the cause of these issues or of toxicity deaths.” Some municipalities pushing back on decriminalization At the UBCM meeting, most representatives for local governments agreed something needed to be done to reduce the death toll from the toxic drug supply but not everyone agreed with how decriminalization had been rolled out. Concerns raised by municipalities included not having enough resources to offer adequate overdose prevention or harm reduction services, public safety, theft, vandalism, the normalization of drug use, discarded drug paraphernalia, human waste, litter and no longer being able to arrest people for public drug use. To push back against decriminalization, Campbell River passed a public nuisance bylaw this summer, which prohibited using drugs within 15 metres of playgrounds, sports fields and courts, bus shelters and most city-owned facilities. Some municipal representatives said they believed they didn’t have the power to open overdose prevention sites, or were being hindered by provincial rules that prohibit indoor smoking. Inhalation is the most common way for people to die from overdose in B.C. right now according to the BC Coroners Service, with 60 per cent of toxic drug deaths in July 2023 happening after someone smoked their drugs. In January this year that number was 73 per cent of all toxic drug deaths. At a press conference last week, Dr. Mark Lysyshyn, deputy chief medical health officer of Vancouver Coastal Health, said people are choosing to smoke their drugs when possible because it allows them to control their dose in hopes of mitigating their risk of overdose. They can smoke a little, wait a bit to see if they overdose, and smoke a bit more, he said, compared to injecting drugs when you take the entire dose at once. Unfortunately due to the high potency and unpredictability of the drug supply people are still overdosing, he said. Dr. Bonnie Henry said provincial rules do not prevent municipalities from opening overdose prevention sites. “I think it’s being used in some communities as a way for councils to not allow OPS [Overdose Prevention Sites],” she said. Brittany Graham, executive director of the Vancouver Area Network of Drug Users, who was also not at the UBCM meeting, said both local and provincial governments are passing the buck when it comes to building local harm reduction services. “Whether its decriminalization, regulation or prescribed safer supply, one government is always blaming another for why they can’t do things,” she said. Graham said governments often download the responsibility for creating local harm reduction services to non-profits, which are already time- and resource-strapped. Governments can also still reject non-profit’s plans, she said. At the September meeting, both the Ministry of Mental Health and Addictions as well as many municipal representatives acknowledged how issues around poverty and homelessness can get lumped in with drug use and decriminalization. Henry said she doesn’t want to see drug use around children, but added “we can’t arrest our way out of this.” She stressed “the solution is not to go back to arresting people, especially when they look homeless,” and noted her concerns around how there are not enough places for people to use safely in the province. There are 47 overdose prevention sites in B.C., including 19 with inhalation services, according to the Ministry of Mental Health and Addictions. Between January 2017 and June 2023 there have been more than 4.1 million visits to these sites and 25,530 overdoses were reversed, with one death. In June 2023 there were 67,641 visits to OPS across the province. But these existing services are nowhere near meeting the actual needs of people who use drugs, Graham said. Most OPS can only fit six to 10 people at a time and are often not located close to where people live, she said. If you have a criminal record you can also be prohibited from going certain places and in a small community this can mean you’re not allowed to visit an OPS, doctor’s office or pharmacy, she added. Smithers Mayor Gladys Atrill said it’s particularly hard for smaller communities to offer adequate harm reduction programs, noting how her community may offer a “long list of services” but most are run by just one person. When asked how smaller communities could better offer harm reduction services, Christine Massey, deputy minister of the Ministry of Mental Health and Addictions, recommended contacting the local health authority to see if an overdose prevention site could be set up at an existing facility, or to use the Lifeguard app. The app can automatically contact emergency services after a person uses drugs if the person fails to respond to prompts on their phone after a set period of time. Henry said other innovations include working with peer-based mobile support services in small communities to help overcome long distances to pharmacies, harm reduction services or doctor’s offices. If you want to reduce homelessness, garbage and human waste in communities, give people public washrooms and housing, stated drug policy analyst Karen Ward; if you want to reduce vagrancy, offer people jobs. ‘Drug use is part of our culture and our society’ There has been an increase in people accessing treatment since January of this year but it’s not yet clear if that is thanks to decriminalization or because public health has reduced stigma and increased services, said Ally Butler, the assistant deputy minister for treatment and recovery for the Ministry of Mental Health and Addictions. Victoria Mayor Marianne Alto was the only person in the meeting to call for the Province to introduce non-prescribed safer supply to combat the ongoing toxic drug crisis, where people who use drugs could access pharmaceutical alternatives to illicit street drugs at their local pharmacy or other regulated distribution centres. “We need to move to legal regulation that acknowledges drug use is part of our culture and our society,” Alto said, noting how drinking alcohol or smoking cigarettes are also drug use, just socially accepted forms of it. “We have tried to get rid of drugs for centuries and have failed. We need to acknowledge it’s here and ensure what we use is not going to kill us.” Around 5,000 people have been able to get prescriptions for the opioid hydromorphone to take instead of illicit street drugs, but this is “a pilot program that is barely working for the people who can access it,” Graham said. The Province estimates around 100,000 people in B.C. have opioid use disorder, and that doesn’t include people who use drugs occasionally or recreationally, who are also at risk of overdosing from the toxic drug supply. “The bigger issue here isn’t that people aren’t worried about drug use in their community— they just don’t want to see homelessness or acknowledge that there are people in their community that aren’t looked after,” Graham said. “Decriminalization is about seeing the harms that the actual system is doing to the individual person and addressing those harms at the system level instead of putting everything on that individual person,” she added. Both Graham and Ward criticized the government’s lack of creativity when it comes to thinking about decriminalization and what an end to prohibitionist policies could look like. Ward pointed to alcohol regulations as an example. In the ’50s an individual needed a licence to consume alcohol and a business needed a licence to sell alcohol, she said. Today the government is involved in every step of alcohol production, distribution, sale and consumption despite everyone being able to make it at home. Alcohol regulations are strict but people still choose to follow them and even enjoy going to a bar—which can also be thought of as a supervised, regulated, controlled consumption site, she said. People can order a drink and know the strength and purity of the substance, which allows them to control their dose. Imagine if we had similar regulations for all drugs and stores where people could go to safely buy or use regulated drugs, she said. “It’s the rule of iron-law prohibition where the greater the enforcement is, the more potent the drugs are,” Ward said. “The flipside is the less enforcement you have the more variety of lower-potency substances you get. Imagine if we brought back coca tea — that’s how you counter the sale of more potent substances.” Michelle Gamage is a Local Journalism Initiative Reporter with The Tyee. This reporting is funded by the Government of Canada and available for republication by other media. See a comment by a Victoria physician with some concerns about BC's safer supply policies on this site.

BC’s status quo approach is not good enough, says a grassroots organization of doctors and teachers. By Michelle Gamage, Local Journalism Initiative Reporter, and Katie Hyslop A WEEK BEFORE the start of school, British Columbia didn’t have an updated back-to-school plan for reducing respiratory infections in schools, including COVID, flu, cold and RSV, says a grassroots organization of doctors, teachers, nurses, scientists, academics and parents. Despite the release of her own study last year showing 80 per cent of kids and youth in the province have contracted COVID at least once, Provincial Health Officer Dr. Bonnie Henry has maintained schools are not a meaningful site of transmission. Protect Our Province BC challenges this by citing an American-Taiwanese study that found 70 per cent of in-household virus transmission began with children, especially when school was in session. Protect Our Province BC says the Province should should pay attention to the southern hemisphere, where respiratory illness season is already well underway—and where countries have seen premature winter breaks, the return of mask mandates and high rates of hospitalization for influenza in children. Photo: Creative Commons Attribution-NonCommercial 4.0 International Public License The Health Ministry was asked, in August, for their strategy for reducing respiratory illness transmission in schools this fall. They responded with an email statement that outlined their strategy. This includes an updated vaccination campaign starting sometime this fall that is expected to target the XBB.1.5 variant, also known as the Omicron subvariant “kraken,” following the latest advice from the National Advisory Committee on Immunization. The kraken variant first started making headlines in January 2023. The Ministry said the vaccine will protect against many closely related subvariants. According to the World Health Network as of July 30, 2023, 7.9 per cent of COVID-19 cases in B.C. were with the XBB.1.5 variant (an additional 9 per cent were with the XBB.1.5.44 variant and 2.2 per cent were with the XBB.1.5.59 variant). The largest single variant was EG.5.1, nicknamed the “Eris” COVID variant, which made up 18 per cent of the total cases. “We’re into the EG.5.1 now,” said Dr. Lynne Filiatrault, co-founder of POP BC. “Where is this [COVID strategy] posted? What has been sent to schools? What has been sent to parents and families?” The Health Ministry says it is also following the National Advisory Committee on Immunization that recommends people get their next booster this fall when a booster that provides the “best protection” will be available. In late August Reuters reported that Moderna and Pfizer vaccines are aimed at the Kraken XBB.1.5 variant but also “show promise” against the Eris EG.5.1 strain. Masking will remain optional in schools, student and staff absenteeism will be monitored and mechanical ventilation systems or HEPA filters will be used in all classrooms in the province, including portables, the Ministry told us. An updated Communicable Disease Guidance for K-12 document is underway by Public Health, they added. The Ministry also said it would distribute COVID-19 rapid tests to schools this fall as part of a “transition” away from PCR tests and that there would not be school-wide vaccination programs for COVID-19 because “we’ve heard clearly from families that parents want to be there when their child is vaccinated and children want their parents there too.” This is exactly what the Province said about schools last September, representatives of POP BC say. But high rates of absences for teachers, school staff and students last year show the strategy wasn’t enough to keep people from getting sick, they say. The provincial plan is also behind the times when it comes to tackling the latest COVID strain, POP BC says. COVID-19 hospitalization rates are currently up in Canada and in the United States, where some schools have already closed because of infection rates for COVID and other communicable diseases. The public has stopped paying attention to COVID, teacher and POP BC co-founder Jennifer Heighton said. It’s important that the government get the message out that COVID is still here and long COVID has lasting health consequences for kids and adults, she added, beyond the 30 days B.C. COVID mortality reporting considers people to be impacted by COVID. “The general public has no idea it’s not like a cold or flu,” Heighton said, adding COVID infections have been linked to increased rates of heart attacks among adults under 45, while adolescents with multiple COVID infections are at an increased risk of developing Post-COVID conditions, better known as long COVID, that include chronic fatigue, organ swelling and Type 1 Diabetes. “Two weeks before school starts, people think that COVID’s benign, that if you’re vaccinated you’re fine, that we’re in a different stage of the pandemic, when actually, we never left,” Heighton said. Preparing for the next wave Protect Our Province tracks COVID through the American Centre for Disease Control, a Walgreens Pharmacy COVID tracker in the U.S., waste water trackers in B.C. and Canada, and the Mortality Tracker for excess mortalities in Canada. They say B.C. should pay attention to the southern hemisphere, where respiratory illness season is already well underway. In Chile, school mask mandates have returned. In Uruguay, winter break began two weeks early because of high infection rates from multiple viruses. In Australia, Filiatrault added, children are making up 80 per cent of hospitalizations from multiple respiratory illnesses this season. POP BC’s strategy for reducing COVID, flu and RSV transmission in schools includes improving school ventilation systems to the latest standards set out by the American Centre for Disease Control and Prevention and the American Society of Heating, Refrigerating and Air-Conditioning Engineers; installing CO2 monitors in every classroom and publicly reporting the results; a new mask mandate for schools, specifying KN95 style or higher protection; admitting COVID is airborne and transmitted through aerosol spray; redistributing the federal government’s stash of rapid antigen tests to schools and families; and ensuring early vaccination of all kids and families for COVID and influenza. “If the government is saying they’re doing enough for ventilation, they’re wrong,” said Heighton, pointing to increased teacher, school staff and student absences last year. “That tells you that the ventilation within those classrooms is not enough, because why else was there illness spreading like wildfire in these classrooms?” According to the BC Centre for Disease Control, influenza season peaked early last year, around the same time there was a spike in RSV infections, as well as COVID, a situation POP BC refers to as a “tripledemic.” Six children died of influenza in the province over a two-week period last fall. From 2015 to 2021 an average of 1.5 kids died from influenza in a year. While there is no current mask mandate for B.C. schools, the Ministry says masks remain an important tool in preventing infection “and should be used in situations where it makes sense to do so,” in addition to getting vaccinated and washing your hands. But with only 16 per cent of kids under four, 20 per cent of five- to 11-year-olds and 15 per cent of 12- to 17-year-olds fully vaccinated in B.C., masks are even more important, POP BC says. Without a mandate and public information campaign, people won’t wear them. Kids under four need two doses to be considered fully vaccinated, five- to 11-year-olds need three doses and 12- to 17-year-olds need four doses. “It should not be politicized the way that it is,” Heighton said, adding similar public health campaigns have already been done for using sunscreen. POP BC questions the quality of school ventilation Since 2020 the provincial and federal governments have spent $219.4 million helping schools upgrade air ventilation and filtration in their buildings, the Health Ministry noted in an emailed statement. It added, “all classrooms and portables in B.C. have mechanical ventilation systems or standalone HEPA filtration units” and school districts conduct regular inspections of HVAC systems. “School districts are recommended to have the capacity to use MERV-13 filters in their HVAC systems,” the ministry added. The ministry also said all school districts are “expected” to meet the indoor air quality standards set by the American Society of Heating, Refrigerating and Air-Conditioning Engineers, adding school districts are responsible for assessing and monitoring their own air quality. In 2023 to 2024 the province will allocate $41 million to upgrade HVAC systems in 101 schools in B.C. as part of a larger $261.1 million fund for school maintenance projects, the ministry added. But POP BC questions government’s claim that schools are properly ventilated. There has been no public accounting for how and where money invested in ventilation was spent or whether ventilation systems have the appropriate HEPA or MERV-13 filters to prevent COVID transmission, they said. School districts have released their own ventilation information, but they vary in terms of detail, Filiatrault noted. For example Surrey School District 36’s site tells you exactly what kind of HVAC filters are used in each room of every school in their district. While some rooms use MERV-13 filters, which are recommended by the BC CDC for COVID prevention, many use lower rated MERV-8, MERV-9 and MERV-11 filters. The Vancouver School District 39 information is broken down by school, but the details provided are about ventilation assessments and upgrades, not a classroom-level breakdown of filters used. This September will be the fourth time schools have reopened since the pandemic was declared in March 2020, said Filiatrault, “and yet parents still don’t know ‘what is the air quality in my kids’ school, in the shared spaces, let alone what is the air quality in my kid’s fully occupied classroom?’” While the Ministry maintains they require schools to follow the American Society of Heating, Refrigerating and Air-Conditioning Engineers ventilation standards, POP questions whether they are following the most recent version, ASHRAE 241, released earlier this year. The Ministry said it is currently reviewing the update and will update its own guidance documents if required. In an emailed statement, the Health Ministry stated they are reviewing ASHRAE 241. POP BC wants carbon dioxide metres in every classroom to measure classroom air quality and flow, with reporting on school air quality made publicly available, like the Boston school district does. Heighton already uses a CO2 monitor in her classroom—in addition to a portable HEPA filter and personally masking at all times—and she noticed CO2 levels go down when her classroom windows are open. “If you don’t have enough new air coming in, then the CO2 levels will go up and up,” she said, adding it is a good indication of how well your HVAC system works. “Crowded, close, closed and poorly ventilated” is what the virus cares about, Filiatrault said, adding that describes B.C. schools. Especially since masks are no longer mandatory for students or staff. Filiatrault and Heighton recommend parents send their kids to school with masks, stay up to date with vaccines, stock up on fever-reducing medicines and rapid tests, and keep their kids home when sick to prepare for the coming school year. “Masks and cleaning the air are variant-proof,” Heighton said. This article was first published in The Tyee. Michelle Gamage is a Local Journalism Initiative reporter with The Tyee. Such journalism, funded by the Government of Canada, is produced under a Creative Commons Licence, so Canadian news media organizations can republish the material for free. Katie Hyslop co-authored this article.