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Diabetes Canada has just released a new Position Statement acknowledging that a low carb and very low carb (keto) diet is both safe and effective for adults with diabetes.

Reflecting back on their 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada release in April 2018 and covered in this article,  Diabetes Canada clarified in today’s  Position Statement that it was not their intention to restrict the choice of individuals with diabetes to follow dietary patterns with carbohydrate intake that were below the consensus recommendation of 45-60% energy as carbohydrate, nor to discourage health-care practitioners from providing low-carb dietary support to individuals who wanted to follow a low-carb meal pattern. 

In the new Position Statement, Diabetes Canada acknowledged what I’ve written about previously, that Diabetes Australia, Diabetes UK, and the American Diabetes Association (ADA) in conjunction with the European Association for the Study of Diabetes (EASD) have developed position statements and recommendations regarding the use of low carbohydrate and very low carbohydrate (ketogenic) diets for people with diabetes. They state that from these previous international position statements and recommendations, several consistent themes have emerged — specifically that low carbohydrate diets (defined as less than <130 g of carbohydrate per day or <45% energy as carbohydrate) and very low carbohydrate diets (defined as <50 g of carbohydrate per day) can be safe and effective both in managing weight, as well as lowering glycated hemoglobin (HbA1C) in people with type 2 diabetes over the short term (<3 months).

Diabetes Canada explained in the publication that they periodically develop position statements in order to address issues that are important for people living with diabetes, as well as their health-care providers and when there is either insufficient data to perform a systematic review, or there is no high level evidence (e.g. double-blind placebo controlled studies).

Diabetes Canada stated that this new position statement was developed in response to emerging evidence. as well as a shift in international consensus regarding lower carbohydrate diets — with the goal of providing important clarification for people living with diabetes, as well as health-care providers. It is their hope that this update will make effective engagement with multi-disciplinary teams easier, as well as avoid inter-professional tensions, as well as clearly identify areas where there are key safety issues and the need for clinical monitoring.

The purpose of the position statement was to summarize the evidence for the role of low carbohydrate diets (<51-130g carbohydrate/day) or very low- carbohydrate diets (<50g carbohydrate/day) in the management of people diagnosed with type 1 and type 2 diabetes.

Summary of the Evidence – type 2 diabetes

Low Carbohydrate Diets

A review of the evidence found that a low carbohydrate diet (<51-130g carbohydrate/day) may be effective for weight loss, improved blood sugar control including a reduction in need for blood sugar lowering medication (anti-hyperglycemic therapies).

Also noted in the position paper is that while other dietary approaches for managing type 2 diabetes may be effective for weight loss and better blood sugar control, they have not achieved this while also reducing the need for blood-sugar lowering medication. Diabetes Canada calls this a  “meaningful outcome”.

Very Low Carbohydrate Diets

Of significance, this new position statement states that a review of the current literature suggests that very low- carbohydrate diets (<50g carbohydrate/day) may be superior to higher carbohydrate diets for improving blood sugar control and body weight, and that it can reduce the need for blood sugar lowering medications in the short term (up to 12 months).

They state that evidence regarding longer-term benefits is limited.

Summary of the Evidence – type 1 diabetes

The new position paper states that “there is very little reliable data and major evidence gaps which make it difficult to make general  recommendations with any confidence” for those with type 1 diabetes.

That said, the paper does state that for those living with type 1 diabetes, significant improvements in outcomes such as lower HbA1C, reduced insulin requirements, less variability in blood sugar and weight loss have been reported by individuals who have chosen to follow a low carbohydrate or very low carbohydrate diet.

Diabetes Canada concludes that “in the absence of clear trial evidence to support generalized recommendations, as well as the positive results experienced by people following low- and very low- carbohydrate diets;

• health-care providers will need to work as partners with individuals seeking to identify an optimal and sustainable dietary pattern that fits with their individual preferences.
• Health-care providers will need to recognize that diverse approaches are required to address the complex challenges of diabetes and obesity.
• Health-care providers should strive to engage with patients in supportive relationships which respect shared decision making. “[1]

Cautions and Safety

Diabetes Canada advised that insulin and/or sulphonylurea doses may need to be reduced or discontinued to avoid hypoglycemia (low blood sugar) in those following a low carb or very low carb diet, and that SGLT2 inhibitors may increase the risk of diabetic ketoacidosis in individuals following low carbohydrate diets. As well, Diabetes Canada states that some added caution may be needed to ensure detection and treatment of hypoglycemia.

Diabetes Canada’s Five Recommendations

1. Individuals with diabetes should be supported to choose healthy eating patterns that are consistent with the individual’s values, goals and preferences.
2.  Healthy low carb or very-low-carb diets can be considered as one healthy eating pattern for individuals living with type 1 and type 2 diabetes for weight loss, improved blood sugar control and/or to reduce the need for blood sugar lowering medications. Individuals should consult with their health-care provider to define goals and reduce the likelihood of adverse effects.
3. Health-care providers can support people with diabetes who wish to follow a low-carbohydrate diet by recommending better blood glucose monitoring, adjusting medications that may cause low blood sugar or increase risk for diabetic ketoacidosis and to ensure adequate intake of fibre and nutrients.
4. Individuals and their health-care providers should be educated about the risk of diabetic ketoacidosis while using SGLT2 inhibitors along with a low carbohydrate diet, and be educated in lowering this risk.
5. People with diabetes who begin a low carbohydrate diet should seek support from a dietitian who can help create a culturally appropriate, enjoyable and sustainable plan. A dietitian can propose ways to modify carbohydrate intake that best aligns with an individual’s values, preferences, needs and treatment goals as people transition to- or from a low carbohydrate eating pattern.

Healthy Low Carb and Very Low Carb Diets

Finally, Diabetes Canada underscores that Canadians both with- and without diabetes who choose to adopt a low or very low-carbohydrate dietary
pattern “should be encouraged to consume a variety of foods recommended in Canada’s Food Guide”, and that “regular or frequent consumption of high energy foods that have limited nutritional value, and those that are high in sugar, saturated fat or salt, including processed foods and sugary drinks, should be discouraged.”

Final Thoughts…

As a Dietitian who has been helping individuals in Canada safely follow low carbohydrate and very low carbohydrate diets for the past 5 years, I am delighted that Diabetes Canada shares the consensus of other international groups that have determined that these diets are both safe and effective for adults to follow in order to get much better blood sugar control, and for weight loss.

More Info?

If you would like more information about how I can help you get started on a low carbohydrate or very low carbohydrate diet, please reach out to me by sending me a note using the Contact Me form on the tab above.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
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Reference

1. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
   Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.

Copyright ©2020 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

Note: This article is a follow-up to an earlier article about COVID-19 coronavirus in the Vancouver area that was posted on February 6th, 2020. Please note this article was updated twice on February 23rd, with the updates posted below.

Provincial health officer Bonnie Henry announced Thursday, February 20th that a woman in her 30s who just returned from Iran this week is British Columbia’s sixth case of the novel COVID-19 coronavirus.  The woman was assessed at a hospital and is now in self-isolation at home in the Fraser Health region. Health officials won’t say which area she is in, but only that the Fraser Health region spans from Burnaby to Hope[1].

Note: The north shore (North Vancouver) is well known for its vibrant Iranian community, but so is Coquitlam, which is part of the Fraser Health region.

Health officials are now investigating details of the woman’s travel and working to determine whether other passengers on her flight home will need to be notified and tested.

This case is unusual in that the travel was to Iran, and not China or Singapore. Dr. Henry said that this is what is called a “sentinel event”, which is “a marker that something may be going on broader than what we expect[1].”

Earlier this week, on February 16th two Canadians returned to British Columbia from having been on the Westerdam cruise, and were asked by officials to put on protective face masks at Vancouver International Airport as an American woman who was on the cruise with them has tested positive for the COVID-19 coronovirus, and both she and her husband have been hospitalized with pneumonia [2,3]. The Global News headline for the story read “COVID-19 fears spike after woman let off cruise ship in Cambodia tests positive“.  The story’s opening paragraph reads, “The feel-good story of how Cambodia allowed a cruise ship to dock after it was turned away elsewhere in Asia for fear of spreading the deadly virus that began in China has taken an unfortunate turn after a passenger released from the ship tested positive for the virus [3].”

A week ago, a 5th case of COVID-19 had been identified in British Columbia in a woman in her 30s who travelled to the Shanghai area of China. “She was not in Hubei province and was not in an area where travel was restricted,” said Dr. Bonnie Henry, B.C.’s Chief Medical Health Officer. ”She came home from Shanghai through YVR (the Vancouver International Airport) and then travelled by private vehicle to her home in the interior,” said Henry. The woman was tested on February 11th, and the lab returned a positive result on Thursday February 13th [4]. Global News reported that they think that the woman’s symptoms started around her time of arrival. Henry said, ”We’re still working out the seating and looking at the flights“.  Global News also reported that “health officials are still working to contact everyone who sat within three rows of the woman to discuss what to do if they show symptoms”. Officials are not saying what flight the woman was on, or where she lives in the interior because “because they don’t want to unnecessarily alarm people“, Henry said [4].

It is also known that 5 million people left Wuhan before quarantine was set up in that city in preparation for the lunar New Year[5]. Where did they go? We know for sure that two people from Wuhan came to Vancouver during that time and that a woman in her 50s with whom they were staying contracted COVID-19 from them [6,7]. Since incubation period for the illness is believed to be up to 14 days and these individuals they were without symptoms while touring Vancouver sites, it is unknown how many individuals in the greater Vancouver area may have also been exposed to the coronavirus over the last few weeks by being in close contact with these three individuals. It is also unknown how many other people from the outbreak area may have come to Canada before the quarantine was in place. 

Some thoughts…

Medical officials are continuing to assure the public that the risks of getting COVID-19 are “low”, but “low” is a relative term.

Risk would certainly be “low” when compared to Wuhan where the coronavirus originated from (based on the sheer number of individuals infected there) and would also be “low” compared to those who were quarantined on the Diamond Princess off of the coast of Japan, but people in the Greater Vancouver area are very much on edge knowing that being within 2 meters (6.5 feet)  for any length of time of those who are contagious may put them at risk. Two meters is the distance between tables in  a restaurant, the distance between people in front and behind in a long line up at a checkout line, or at popular locations including the airport. Given that people can have no symptoms whatsoever and be contagious for 14 days has many people concerned. 

In addition to a growing outbreak of COVID-19 in Iran, also of concern is the recent emergence of hundreds of cases of COVID-19 in Seoul, South Korea — as both of these countries have strong ties to local communities, and neither country is currently restricting travel.

Distance Consultations

Over the past decade that I have provided services via Distance Consultation they had become increasingly popular with local-area clients as it saved them travelling, booking time off work, or arranging childcare. As events related to coronavirus have unfolded, many local clients are glad to have the ability to consult with me remotely, especially given my experience in doing so. 

You can find out more about Distance Consultations by clicking on the tab above.

More Info?

If you would like more information about the services that I provide, please have a look under the Services tab or in the Shop. If you have service-related questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd
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Update: February 23, 2020: Several media outlets [8,9] are reporting that the woman that tested positive for the new coronavirus and had recently flown from Iran, also flew from Montreal to Vancouver on Valentine’s Day, February 14th. The BC Provincial Health Authority (PHSA) advised Air Canada that it plans to contact all passengers who flew out of Montreal that day and who were seated within three rows of the woman so that they can monitor their health for a 14-day period and report any symptoms to a health professional [8.9].

Global News reported later this afternoon that the Fraser Health Authority sent a letter to all school districts in its region on Friday, which includes Burnaby, New Westminster, Maple Ridge, Pitt Meadows and the Tri-Cities — warning them that contacts of the woman with coronavirus ”may have attended schools in the region and are currently isolated.”  Fraser Health’s medical health officer Ingrid Tyler wrote in the letter that ”these contacts were not showing any signs or symptoms of illness while attending school, and remain well” and the health authority has assured that “there is no public health risk at schools in the region” and “no evidence that novel coronavirus is circulating in the community” [10].

 

Copyright ©2020 LCHF-RD (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

1. Globe and Mail, Andrea Woo, B.C. hit with sixth case of coronavirus after woman returns from Iran, https://www.theglobeandmail.com/canada/british-columbia/article-bc-hit-with-sixth-case-of-coronavirus-after-woman-returns-from-iran/
2. CBC News, Austin Grabish, As Canadians return home from Westerdam cruise, health officials urge them to self-isolate, February 16, 2020 https://www.cbc.ca/news/canada/british-columbia/westerdam-cruise-canadians-return-home-1.5466131
3. Global News, Sopheng Cheang, Eileen Ng, Grant Peck (Associated Press), COVID-19 fears spike after woman let off cruise ship in Cambodia tests positive, February 17, 2020, https://globalnews.ca/news/6559821/cambodia-cruise-ship-coronavirus-positive/
4. GlobalNews, Stuart Little, B.C. identifies 5th presumptive case of COVID-19, woman who travelled near Shanghai, https://globalnews.ca/news/6552744/british-columbia-covid-19-update/
5. CTVNews, Erika Kinetz, Where did they go? Millions left Wuhan before quarantine. February 9, 2010, https://www.ctvnews.ca/health/where-did-they-go-millions-left-wuhan-before-quarantine-1
6. CityNews 1130, Paul James and Kathryn Tindale, Health officials track coronavirus in Metro Vancouver, risk remains low, posted Feb 5, 2020 11:31 am PST, last Updated Feb 5, 2020 at 11:32 am PST,  https://www.citynews1130.com/2020/02/05/virus-expert-tracking-infected/
7. National Post, Richard Warnica, Fifth suspected coronavirus case in Canada is B.C. woman who had ‘close contact’ with Wuhan visitors, Posted February 4, 2020 and 11:33 PM EST, https://nationalpost.com/news/canada/fifth-suspected-coronavirus-case-in-canada-is-b-c-woman-who-had-close-contact-with-wuhan-visitors
8. Montreal Gazette, Susan Schwartz, February 23, 2020, Passenger from Iran on flight from Montreal to Vancouver tests positive for new coronavirus, https://montrealgazette.com/news/local-news/passenger-from-iran-on-flight-from-montreal-to-vancouver-tests-positive-for-new-coronavirus
9. CBC, B.C.’s 6th presumptive COVID-19 case flew from Montreal to Vancouver on Feb. 14, https://www.cbc.ca/news/canada/british-columbia/bc-coronavirus-flight-montreal-vancouver-1.5473283
10. Global News, Sean Boynton, Passenger on Air Canada flight to Vancouver is not a new case of COVID-19: B.C. officials, Feb 23 2020 2:11 pm, updated 5:18 pm), https://globalnews.ca/news/6586274/covid19-air-canada-vancouver-montreal/

Note: This post is based on two articles about coronavirus in the Vancouver area, one which was published by the National Post on Tuesday, February 4, 2020 and the other that was published on the News 1130 website on Wednesday February 5, 2020, and represent my thoughts on the subject.] Please see the most recent updates, below.

Secondary Coronavirus Case in Metro Vancouver

This past Tuesday, February 4, 2020 BC’s provincial health officer, Dr. Bonny Henry announced that a woman in her 50’s who had not visited China recently but who had relatives visiting from Wuhan, China the past several weeks had tested positive for the coronavirus, and is now in hospital [1] in the Vancouver area.  Based on several reports, her relatives left Wuhan prior to the lock down of the city resulting from the coronavirus epidemic, but since incubation period for the illness is believed to be up to 14 days, they were without symptoms while recently touring Vancouver sites. The woman with whom they were visiting has since contracted coronavirus, but it is currently unknown how many individuals in the greater Vancouver area may have also been exposed to the coronavirus over the last few weeks.

An article on News 1130 published Wednesday, February 5th stated that “medical officers are tasked with tracking down anyone who may have been in contact with carriers of the (coronavirus) virus” [1]. The article went on to elaborate that “anyone who would be in close range of about two meters (~6.5 feet) of an individual who’s infected and spends a significant amount of time in that space would be at highest risk for picking it up”, said infectious disease expert Susy Hota of the University of Toronto’s Faculty of Medicine. She added that “There’s no guarantee that they will pick it up, in fact, most people won’t“.  Not mentioned is the risk associated with the more common way of catching viruses, such as by someone contagious sneezing into their hand and then touching surfaces we then touch, such as public restroom door knobs.

Dr. Michael Gardam, who is an infectious disease specialist at Toronto’s Humber River Hospital was reported in the National Post article to have said, “We’re all worried about the potential of this becoming a problem in Canada. I don’t think this is going to be a short-term thing,” he said and added ”because of the nature of how it’s spreading and what’s happening in China, we could unfortunately be dealing with this story for the next two years[2].”

The National Post highlighted that what makes this most recent case of coronavirus in Vancouver significant is that the person had not travelled to China. Dr. Isaac Bogoch, an infectious disease specialist at the University of Toronto was reported to have said, ”That’s called secondary spread. That’s a problem[2].“

The story published on News 1130 web page yesterday elaborated that medical officials in the Vancouver area “want to reach out to the close contacts of that individual” which they explain tend to be household members, or those who interact very commonly with the individual(s). “Each person contacted will be assessed for early symptoms (of coronavirus) and given information on how to react if symptoms develop”.  Susy Hota of U of T’s Faculty of Medicine was reported to say “while tracking of those people will be underway, the risk of other people being infected remains low“.

Final thoughts…

“Low” is a relative term. Risk would certainly be “low” when compared to Wuhan where the coronavirus originated from, based on the sheer number of individuals infected there, and would also be “low” compared to those currently quarantined on cruise ships off the coast of Japan and Hong Kong, but it is unknown how many people in the Metro Vancouver area were within 2 meters of this woman and her relatives for any significant amount of time while they were in Vancouver over the last several weeks. These individuals had no symptoms of having coronavirus at the time, but based on the known two-week incubation period before people manifest symptoms, people that were within 2 meters of them for an extended period of time may currently be contagious.  It would seem, in my understanding that this could include those seated at an adjacent table in a restaurant, standing nearby in a crowded shop for significant amount of time, or waiting in the same check-out line at a store.

There is a high degree of concern about coronavirus among the people I speak with on a daily basis; with most concerned that they may be at risk of contracting the virus, or now wondering if they have already been exposed to it, and have not yet manifested symptoms.  While health officials continue to encourage people that the risk of getting coronavirus in Metro Vancouver is “low”, people remain concerned about what is not known.

Since I already had over a decade of experience providing Dietetic services via Distance Consultation, and almost two-thirds of my clients already chose to meet with me remotely, it seemed to makes good sense at this time for me to provide all services in this manner.

You can find out more about Distance Consultations by clicking on the tab above. 

Please see updates on this story, below.

More Info?

If you would like more information about the services that I provide, please have a look under the Services tab or in the Shop. If you have service-related questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

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UPDATES

(February 8, 2020): While not directly related to the current situation in Vancouver, this new story indicates how this virus is spreading without any direct or secondary connection to China. Five British nationals have been diagnosed with the new coronavirus at a French ski resort, and apparently caught it from a British national who had recently visited Singapore and had attended a business meeting from January 20 to 23 which had business delegates from around the world. None of the UK nationals had visited China [3], so this would not be “secondary spread” of the virus, as in Vancouver, but tertiary spread. Vancouver is a major city and Canadian Pacific port hub, with ships arriving daily. It is concerning that coronavirus is now being transmitted in other countries from those who have not visited China.

(February 9, 2020): It is now known that 5 million people left Wuhan before quarantine was set up in that city [4], in preparation for the lunar New Year. Where did they go? We know for sure that 2 came to Vancouver, and it is unlikely that they were the only ones. It is unknown how many more people from the outbreak area came to Canada before the quarantine was in place.

(Feb 11, 2020): Spread of the novel coronavirus (dubbed Covid-19) is suspected to be linked to an outbreak at a single shopping mall near Beijing, China and none of the 33 people that worked or shopped there had history of travel to Wuhan[5].

(Feb 14, 2020): A fifth case of Covid-19, the novel coronovirus has been identified in British Columbia in a woman in her 30s who travelled to the Shanghai area of China. “She was not in Hubei province and was not in an area where travel was restricted,” said Dr. Bonnie Henry, B.C.’s Chief Medical Health Officer. ”She came home from Shanghai through YVR (the Vancouver International Airport) and then travelled by private vehicle to her home in the interior,” said Henry. The woman was tested on Feb. 11th, and the lab returned a positive result on Thursday February 13th [6]. Global News reported that they think that the woman’s symptoms started around her time of arrival. Henry said, ”We’re still working out the seating and looking at the flights“.  Global News also reported that “health officials are still working to contact everyone who sat within three rows of the woman to discuss what to do if they show symptoms”. Officials are not saying what flight the woman was on, or where she lives in the interior because “because they don’t want to unnecessarily alarm people”, Henry said [6].

(Feb 17, 2020) Two Canadians who returned to British Columbia yesterday (Sunday) from having been on the Westerdam cruise were asked by officials to put on protective face masks at Vancouver International Airport as an American woman who was on the cruise with them has tested positive for the Covid-19 coronovirus, and both she and her husband have been hospitalized with pneumonia [7,8]. The Global News headline for the story read “COVID-19 fears spike after woman let off cruise ship in Cambodia tests positive”.  The story’s opening paragraph reads, “The feel-good story of how Cambodia allowed a cruise ship to dock after it was turned away elsewhere in Asia for fear of spreading the deadly virus that began in China has taken an unfortunate turn after a passenger released from the ship tested positive for the virus” [8].

 

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Copyright ©2020 LCHF-RD (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

1. CityNews 1130, Paul James and Kathryn Tindale, Health officials track coronavirus in Metro Vancouver, risk remains low, posted Feb 5, 2020 11:31 am PST, last Updated Feb 5, 2020 at 11:32 am PST,  https://www.citynews1130.com/2020/02/05/virus-expert-tracking-infected/
2. National Post, Richard Warnica, Fifth suspected coronavirus case in Canada is B.C. woman who had ‘close contact’ with Wuhan visitors, Posted February 4, 2020 and 11:33 PM EST, https://nationalpost.com/news/canada/fifth-suspected-coronavirus-case-in-canada-is-b-c-woman-who-had-close-contact-with-wuhan-visitors
3. Global News, Marine Pennetier, 5 UK Citizens Contract Coronavirus at French Ski Resort, February 8, 2020, https://globalnews.ca/news/6525402/5-uk-coronavirus-resort/
4. CTVNews, Erika Kinetz, Where did they go? Millions left Wuhan before quarantine. February 9, 2010, https://www.ctvnews.ca/health/where-did-they-go-millions-left-wuhan-before-quarantine-1
5. New York Times, Coronavirus Update: Quarantine ordered as cases are linked to shopping centre,  https://www.nytimes.com/2020/02/11/world/asia/coronavirus-china.html
6. GlobalNews, Stuart Little, B.C. identifies 5th presumptive case of COVID-19, woman who travelled near Shanghai, https://globalnews.ca/news/6552744/british-columbia-covid-19-update/
7. CBC News, Austin Grabish, As Canadians return home from Westerdam cruise, health officials urge them to self-isolate, February 16, 2020 https://www.cbc.ca/news/canada/british-columbia/westerdam-cruise-canadians-return-home-1.5466131
8. Global News, Sopheng Cheang, Eileen Ng, Grant Peck (Associated Press), COVID-19 fears spike after woman let off cruise ship in Cambodia tests positive, February 17, 2020, https://globalnews.ca/news/6559821/cambodia-cruise-ship-coronavirus-positive/