October 2021 Board of Health Meeting

Meeting Documents

Meeting held via video: https://youtu.be/ihy4DY9cdU8

  1. Call to Order
  2. Agenda Approval
  3. Announcement of Conflict of Interest
  4. Board Elections
    1. Audit Committee Member
  5. Update (Dr. S. Nesathurai)
    1. COVID-19 Update
  6. Approval of Minutes
    1. Regular Board Meeting: September 16, 2021
  7. Business Arising
    1. Q2 Report to the Ministry (L. Gregg)
  8. Consent Agenda
    1. INFORMATION REPORTS
      1. Infection Prevention and Control Hub (K. McBeth)
      2. COVID-19 Surveillance and Epidemiology (N. Dupuis)
      3. Communications Recap (E. Nadalin)
    2. RESOLUTIONS/RECOMMENDATION REPORTS – None
  9. New Business
    1. CEO Quarterly Compliance (N. Dupuis)
    2. Fall Immunization Plan (K. McBeth)
    3. Project Governance Committee – Review of Membership (N. Dupuis)
    4. alPHa Fall Symposium, November 2021 (N. Dupuis)
  10. Correspondence
    1. City of Hamilton, Mayor's Office – Letter to Hon. Christine Elliott – Regional Modernization and Support for Local Public Health
    2. Haliburton, Kawartha, Pine Ridge District Health Unit – Letter to Hon. Christine Elliott – Ongoing government financial support for local public health
    3. Grey Bruce Public Health Unit – Letter to Hon. Christine Elliott – In support of Haliburton, Kawartha, Pine Ridge District Health Unit's letter to Christine Elliott – Ongoing government financial support for local public health
    4. Corporation of the City of Windsor – Council Services – Council Decision CR377/2021 to adopt a Regional Active School Travel Charter
  11. Committee of the Whole (Closed Session in accordance with Section 239 of the Municipal Act)
  12. Next Meeting: At the Call of the Chair November 18, 2021 – Via Video
  13. Adjournment

SUBMITTED BY:

Ramsey D’Souza, Manager of Epidemiology and Evaluation

DATE:

October 2021

SUBJECT:

COVID-19 Surveillance and Epidemiology


BACKGROUND

Overview

The Epidemiology & Evaluation department conducts on-going population health assessment and surveillance. The data and surveillance for COVID-19 plays an integral role in understanding and managing the pandemic locally. The evidence provides information on how the pandemic has and is evolving, assessing the risk and severity, and develop timely interventions to limit further spread in the community.

Trends

In the month of September 2021, the health unit reported 1,542 confirmed cases of COVID-19. This is a 14% decrease in case counts compared to the previous month of August 2021. Similarly, the monthly case rate for September was 356.8 cases per 100,000 population, which is lower compared to the monthly rate in August (312.1 cases per 100,000 population). In Ontario, during the month of September, the case rate was 139.6 cases per 100,000 population. This is approximately 2.6 times lower compared to the rate of Windsor-Essex County.

Age and Gender

Approximately 51% (793) of the cases were among females and 48% among males. A disproportionately (26%) higher number of cases, in September 2021,  were reported among those 0 to 18 years of age, followed by 19% among those 19 to 29 years of age, and 17% in the 30 to 39 year age group. Comparatively, from the onset of the pandemic locally (March 1, 2020 to September 30, 2021), 14% of our cases were in the 0 to 19 age group.

Municipal Distribution

The Town of Leamington had the highest case rates (447.1 cases per 100,000 population), followed by the Town of Kingsville (443.0 cases per 100,000 population) and the City of Windsor (376.0 cases per 100,000 population). However, looking at the distribution of cases, 58% of cases were from the City of Windsor, 9% from Leamington and 8% from Lakeshore.

Risk Factors

For the month of September 2021, the top five risk factors reported were an elementary or secondary student (11.2%), farm worker (3.2%), healthcare worker (2.4%), resident of a congregate living setting (1.8%) and a student in a childcare setting (1.4%).

Variants of Concern (VOCs)

Of the 1,542 cases reported in the month of September, genomic sequencing results were available for 1,391 cases (90% of cases). Overall, 78% of cases reported were due to the Delta variant (B.1.617.2), 12% of cases reported results without a variant, and 10% were not sequenced to identify a mutation or a VOC.

Source of Acquisition

Approximately, 32% of cases in September 2021 acquired COVID-19 from their household contact, 17% from a close contact outside of their household, 7% due to being related to an outbreak, and 3% from travel-related outside of the province (e.g., to another province and/or outside of Canada).

Outcome Status

Of the 1,542 cases reported in September 2021, 76% (1,175) had their infection resolved, 268 cases (18%) were active and being followed by the health unit, and 5.4% (83) of cases were lost to follow-up. Seventeen deaths were reported in September 2021 due to COVID-19.

Vaccination Status

Over 34,500 doses were administered to Windsor-Essex County residents in the month of September compared to 31,700 doses in the month of August. This represents a 9% increase for the month of September 2021. Approximately 51% of the doses administered were second doses to complete a vaccination, 39% were first doses to individuals who were previously unvaccinated, and 10% among those in the highest risk priority groups (e.g., residents of long-term care and retirement homes).

Among the 1,542 cases reported in September 2021, 66% were unvaccinated (or not eligible to receive a vaccine), 23% were fully vaccinated, 6% were partially protected with one dose, and 4% were not yet protected after receiving the first dose. Among the 775 unvaccinated cases, approximately 48% were among those 0 to 18 years of age which includes children who were ineligible to receive the vaccine.

CURRENT INITIATIVES

The health unit will continue to monitor and provide epidemiological expertise on COVID-19 to internal leadership, community partners, and residents to support evidence-informed decision-making. This includes daily epidemiological updates, weekly epidemiological presentations to the community and supporting policy decisions through data driven approaches.

CONSULTATION:

The following individuals were contributed to this report: Bridget Irwin, Scott Miller, Karanveer Banipal, Anum Khan, Noor Al-Azary

SUBMITTED BY:

Kristy McBeth, Director, Health Protection

DATE:

October 2021

SUBJECT:

Infection Prevention and Control (IPAC) Hub


BACKGROUND

Ontario Health has identified organizations including hospitals, public health units and others from across the province to lead local Infection Prevention and Control (IPAC) Hubs (Ministry of Health, 2020). These organizations work with partners from across the local health system who have IPAC expertise to ensure that this specialized guidance and support is available to local congregate living settings though a one-window model.

IPAC Hubs:

  • Identify and monitor IPAC training and practice needs within their catchment area - including in congregate living settings funded and overseen by the Ministry of Health (MOH), Ministry of Long-Term Care (MLTC), Ministry of Seniors and Accessibility (MSAA), Ministry of Municipal Affairs and Housing (MMAH) and the Ministry of Children, Community & Social Services (MCCSS).
  • Strengthen current partnerships and broker new ones; supporting a network of IPAC service providers and experts; working to align local resources to meet IPAC needs within congregate living settings for both prevention and response. Services will be allocated according to a risk-based framework.
  • Bring forward and escalate issues of concern that are outside of the scope of IPAC through established mechanisms with ministry partners.

Local public health and Public Health Ontario (PHO) are key partners in each local IPAC Hub. Working in coordination with the IPAC Hub, public health partners support the provision of IPAC knowledge, training and expertise, and build on existing local partnerships. In addition to contributing to IPAC Hubs as experts, the local public health unit retains the responsibility to oversee the management of outbreaks. Local public health units also have a key linkage to Ministry of Labour, Training, and Skills Development (MLTSD), but does not replace the duties employers of congregate living organizations have to notify the MLTSD as required under the Occupational Health and Safety Act, 1990 and other relevant requirements.

CURRENT INITIATIVES

In collaboration with our local IPAC Hub members, and the current Hub lead Windsor Regional Hospital (WRH), it has been determined that in order to most effectively utilize existing and future human and financial resources, that the WECHU would transition to the role of IPAC Hub for lead for Windsor-Essex effective October 2021. Funding for this initiative, received through Ontario Health, will be allocated to the WECHU to support program deliverables starting in October 2021. This work will be performed through augments to staffing in the Environmental Health Department and will also include FTE allocations from existing staff including Public Health Inspectors. The WECHU’s IPAC Hub program will be an inter-disciplinary team of Public Health Inspectors and Public Health Nurses under the management of a certified Infection Control Practitioner. The current funding for this Hub program is in place until March 31, 2022.

Some of the main WECHU Responsibilities as the local IPAC Hub lead for Windsor and Essex County include:

  • The creation of implementation targets and monitoring of progress;
  • The establishment of local IPAC Hub priorities for service delivery;
  • Leading communication with Hub Partners (Public Health Ontario, hospitals and other providers) and congregate living settings in our defined catchment area
  • Maintaining detailed financial records of expenses and supporting weekly reporting requirements.

The WECHU will continue to work collaboratively with partners in the Hub framework with the new model in place in order to facilitate enhanced local supports for infection prevention and control strategies within congregate settings of our community.

DOCUMENTS:

Ministry of Health. (2020, September). Infection Prevention and Control Hubs. Retrieved from IPAC Hub Program Description:
https://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/d…

 

Board Members Present:

Gary McNamara, Joe Bachetti, Tracey Bailey, Rino Bortolin, Fabio Costante, Gary Kaschak (4:07 pm), Judy Lund, Robert Maich (4:12 pm), Ed Sleiman, Larry Snively

Administration Present:

Nicole Dupuis, Dr. Shanker Nesathurai, Felicia Lawal, Kristy McBeth, Eric Nadalin, Dan Sibley, Lee Anne Damphouse

Administration Regrets:

Lorie Gregg


QUORUM:  Confirmed

  1. Call to Order
    Board Chair, Gary McNamara, called the meeting to order at 4:03 p.m.
  2. Agenda Approval

    Moved by: Judy Lund
    Seconded by: Rino Bortolin
    That the agenda be approved.
    CARRIED

  3. Announcement of Conflicts of Interest – None
  4. Board Elections

    1. Audit Committee Member
      Nominations for Audit Committee Member
      The Chair opened the floor for nominations for a Member of the Audit Committee, noting that Administration had received two (2) written nominations; one (1) for Tracey Bailey, and one (1) for Robert Maich.  The Chair asked for nominations from the floor (three times).  Given that there were no further nominations, nominations for an Audit Committee Member were closed.  The Chair asked Tracey Bailey if she accepted the nomination – Tracey Bailey accepted.  The Chair asked Robert Maich if he accepted the nomination – Robert Maich accepted.  Tracey Bailey and Robert Maich were appointed as a Members of the Audit Committee by acclamation.

      G. McNamara asked if Tracey Bailey, as Board Treasurer, would automatically be appointed to the Audit Committee.  N. Dupuis noted that this is not reflected as a requirement under the Audit Committee Terms of Reference or the Board By-Laws.  

      N. Dupuis also recommended that the WECHU recruit one external member to fulfill committee composition requirements, and to bring an outside perspective. 

      Moved by: Rino Bortolin
      Seconded by:  Gary Kaschak
      That the WECHU recruit an external Audit Committee Member.
      CARRIED

  5. Update (Dr. S Nesathurai)
    1. COVID-19 Update

      Dr. S. Nesathurai said that the Windsor-Essex region currently has a lower number of positive COVID-19 cases than what was being reported at the last Board of Health meeting, but the burden is still significant in our communities with outbreaks at businesses, schools and the hospitals.  Cohorts of over 300 young people have been dismissed from schools due to exposure to COVID 19, and our key goal is to keep schools open for instruction. Two thirds of eligible students are vaccinated and one third are not.  We are over a year and a half into the pandemic and health care workers are fatigued. 

      Although COVID-19 is the number one public health concern, Dr. S. Nesathurai wants to bring to light the current opioid crisis which requires more public attention.  In Ontario in 2020 about 2,400 people died from opioid related deaths compared to about 550 who perished in automobile accidents.  Opioid deaths are four time higher than car accidents.  In 2020 in Windsor-Essex we reported 420 cases and approximately 80 deaths.  We need to consider focusing our attention here.  About one-fifth, or twenty percent of individuals who die by overdose die with someone else in attendance. That is where Naloxone comes in to play and can help save a life.  We would ask those who are using not to use alone and to get a Naloxone kit.  COVID is a priority but we also need to focus on other public health priorities.  Naloxone kits are free of charge and our Windsor-Essex Community Opioid and Substance Strategy (WECOSS) website https://wecoss.ca/ has all of this information on where people can get one including the list of participating pharmacies.  E. Nadalin noted that there is a direct link on our website where to obtain these kits from various community partners and we act as a community hub.  The bulk of the kits are distributed to pharmacies, making them easily accessible when filling prescriptions.  

      Moved by: Judy Lund
      Seconded by: Ed Sleiman
      That the information be received.
      CARRIED

  6. Approval of Minutes
    1. Regular Board Meeting:  September 16, 2021

      Moved by: Judy Lund
      Seconded by: Joe Bachetti
      That the minutes be approved.
      CARRIED

  7. Business Arising
    1. Q2 Report to the Ministry (L Gregg)
      N. Dupuis noted that the WECHU submitted its Q2 Report to the Ministry.  We will defer this portion of the meeting to next month when L. Gregg is available to present

  8. Consent Agenda
    1. INFORMATION REPORTS
      1. Infection Prevention and Control Hub (K McBeth)
        The funding for this initiative flows through Ontario Health to our hospitals.  We are working in collaboration with Windsor Regional Hospital (WRH), and have an agreement to take over this work which aligns with the work of public health.

      2. COVID-19 Surveillance and Epidemiology (N. Dupuis)
        To be brought to the Board for information.

      3. Communications Recap
        To be brought to the Board for information.

        Moved by: Gary Kaschak
        Seconded by: Ed Sleiman
        That the above information be received.
        CARRIED

    2. RECOMMENDATION REPORTS - None
  9. New Business
    1. CEO Quarterly Compliance – July 31, 2021 to September 30, 2021 (N. Dupuis)
      N. Dupuis brought the report to the board for information, noting there is nothing out of the ordinary to report. 

      Moved by: Rino Bortolin
      Seconded by: Judy Lund 
      That the information be received.
      CARRIED

    2. Fall Immunization Plan
      N. Dupuis advised that the Ministry has requested a significant vaccination plan from the WECHU for the fall of 2021 and into the new year.  This plan includes all immunizations, i.e. Influenza, ISPA (Immunization of School Pupils Act) and COVID-19.  We are currently in a good position due to the hard work by our staff under the leadership of Kristy McBeth and community partners.  K. McBeth noted that the immunization plan is in three sections.

      1.    Influenza Vaccine 
      We are well underway with influenza vaccines.  The hospitals and LTCHs/RHs have received them in September.  The vaccine has also been distributed to 214 primary care providers and pharmacies, including the high dose vaccine for the 65 plus population.  To date, 115,200 influenza vaccines have been administered in our communities, an increase from 97,000 last year. We’ve seen an increase in demand and in our supply. The province is encouraging people to get the flu vaccine, and we have received guidance from the ministry on co-administering the flu and COVID-19 vaccines. NASI has indicated that it is safe to co-administer the COVID vaccine with other vaccines. We are working with our partners and mobile clinics, particularly in high-risk neighbourhoods, around messaging, and the vaccine is free to all residents of Ontario. Dr. S. Nesathurai said he believes there has been a drop globally around influenza cases due to masking and public health measures, but will circle back at the next board meeting with more information.

      2.    COVID-19 Vaccine
      COVID-19 vaccines commenced January 1, 2021 and will be ongoing to January 1, 2022.  We have completed 3rd doses locally for all of our LTCHs/RHs, and there will be some follow up for those who have not yet reached the 5 month timeline between vaccines. All of this work is being done in the background by our front line WECHU staff. Individuals who are considered high risk, immuno-compromised or vulnerable, are eligible for a 3rd dose of the vaccine. J. Bachetti asked about those that are homebound and if they are eligible for the 3rd dose.  K. McBeth advised that the LHIN had worked with homebound individuals on the first and second doses, but many are currently not eligible, depending on what their medical condition may be.  We can still support once they become eligible. 

      First and second doses are still considered priority and we continue to support the mass vaccination site at Sears.  Support from CRST, EMS and ESHC will continue with clinics in community centres, buses, parks, and other mobile locations.  We continue to work with school boards for the 12-17 age group.

      Immunization planning for the 5-11 year age group will be a big component for fall.  Providing options and more opportunity for vaccination is key. We are engaging with primary care providers and are hoping for an increased uptake for this group by accessing their family doctors.  Pharmacies and mobile sites will be an option as well to support this age group.  The strategy will be different for this group and we will need to revise various segments of the mass clinic, the size of syringes, chairs, mats on floor, to make them more comfortable and alleviate any feelings of anxiety. 

      E. Sleiman asked if vaccine has to occasionally be thrown out due to open vials or expiry.  K. McBeth said as part of vaccine management we never want to throw out supply.  There are limitations if vials are open and at the end of the day there are some doses that we cannot use as they are multi-use vials and have to be allocated.  Zero wastage is our goal.

      3.    School-age Immunization
      Due to school closures during the pandemic we had to change our school immunization strategy.  Our staff will be in the schools in November administering the first round of vaccines, and again in the spring for the second round.  We also have support from primary care providers. We will offer catch up clinics in December and January and are also offering in-house clinics in Windsor and Leamington. L. Snively asked if we had numbers of our youth vaccinated.  K. McBeth advised that our WECHU Epidemiology team has this information on the Dashboard on our website, broken down by age and postal code.  Numbers are going up, but not substantially.  We have seen a steady decline over the last month or so at our mobile clinics. Daily number were at 200-300 attendees, and now can be down to as low as single digits.  We have benefited greatly from the mass site at Sears, and pharmacies have picked up a good amount of traffic.

      Moved by: Larry Snively
      Seconded by: Gary Kaschak
      That the information be received.
      CARRIED

    3.  

      Project Governance Committee – Review of Membership 
      The Project Governance Committee’s (PGC) composition is made up of 6 Board of Health members; 2 City representatives (Rino Bortolin and Fabio Costante); 2 County representatives (Gary McNamara and Joe Bachetti); 2 provincial appointees (Judy Lund and Robert Maich) along with the CEO, Nicole Dupuis, and Director of Corporate Services, Lorie Gregg.  The Terms of Reference were included in this month’s board package for information.

    4. alPHa Fall Symposium
      Information on the alPHa Fall Symposium was brought forward for information.  The conference will be held virtually and is a one day session.  The cost for registration is $149 per person, plus HST.  In the past we have limited the number of attendees.  Given what is happening in public health and that the conference is being held virtually, we are encouraging any board or leadership team members who wish to attend to do so, and to reach out to Lee Anne Damphouse for registration.  An email went out to today with further conference details. G. McNamara said he would be interested in attending.

      Moved by: Judy Lund
      Seconded by: Ed Sleiman
      That the information be received.
      CARRIED

  10. Correspondence
    1. City of Hamilton, Mayor’s Office – Letter to Hon. Christine Elliott – Regional Modernization and Support for Local Public Health

    2. Haliburton, Kawartha, Pine Ridge District Health Unit – Letter to Hon. Christine Elliott – Ongoing government financial support for local public health

    3. Grey Bruce Public Health Unit – Letter to Hon. Christine Elliott – In support of Haliburton, Kawartha, Pine Ridge District Health Unit’s Letter to Christine Elliott – Ongoing government financial support for local public health

    4. Corporation of the City of Windsor – Council Services – Council Decision CR377/2021 to adopt a Regional Active School Travel Charter

      Moved by:  Rino Bortolin
      Seconded by: Ed Sleiman
      That items 10.1, 10.3, 10.4 be received for information, and that the WECHU prepare a letter of support for item 10.2.
      CARRIED

  11. Committee of the Whole (CLOSED SESSION, in accordance with Section 239 of the Municipal Act)

    The Board moved into Committee of the Whole at 4:55 pm
    The Board moved out of Committee of the Whole at 5:14 pm

  12. Next Meeting: At the Call of the Chair, or November 18, 2021 – Via Video

  13. Adjournment

    Moved by: Fabio Costante
    Seconded by: Judy Lund
    That the meeting be adjourned.
    CARRIED

    The meeting adjourned at 5:15 pm.

RECORDING SECRETARY: L. Damphouse

SUBMITTED BY: N. Dupuis

APPROVED BY:

  1. Period covered by this report:  April 1, 2021 to June 30, 2021
  2. For the period covered by this CEO Quarterly Compliance Report:
    1. The undersigned has personal knowledge of the matters herein reported or has made due inquiry with respect to the same.
    2. Except as reported in any previous CEO Quarterly Compliance Report, the undersigned reports as follows:
      1. that the Health Unit has been in material compliance with all laws, regulations, orders, judgments or decrees applicable to it.  Without limiting the generality of the foregoing the Health Unit is current in respect of all tax and related withholding and remittances required by law;
      2. the Health Unit has been in material compliance with its By-laws;
      3. the Health Unit has been in material compliance with all other Board resolutions;
      4. the Health Unit has been in material compliance with all contracts and commitments to which the Health Unit is a party including without limitation all funding and accountability agreements;
      5. the Health Unit is current with respect to the payment of all remuneration (including salary and benefits) to its employees;
      6. there are no material variances between what is contemplated by the Operational Plan and what in fact transpired or appears likely to transpire
      7. more specifically, no material changes are required in respect of financial resource allocation plans to address shifts in need and capacity
      8. no material adverse change has occurred in the operations of the Health Unit or its assets and liabilities taken as a whole
      9. there have been no material breaches of the Ethics Code of Conduct by anyone who is subject to it;
      10. there have been no unplanned terminations of any Health Unit employees;
      11. there have been no claims made pursuant to any insurance policies maintained by the Health unit; and,
      12. nothing has come to the attention of the undersigned which would materially adversely change any previous CEO Quarterly Compliance Report, except as detailed below:
        Items (vi), (vii), and (viii) have been revised due to the COVID -19 pandemic as follows:

On March 17, 2020, the Province of Ontario enacted the Emergency Management and Civil Protection Act, R.S.O. 1990, c. E.9. (“the Act”), to support efforts to contain the spread of COVID-19, in our communities.  The Act supports public health units to, regardless of their collective bargaining agreements, suspend services, redeploy staff as deemed appropriate, modify hours of work, cancel and or defer vacations, utilize part-time/contract staff to perform the duties and responsibilities of bargaining unit staff and suspend the grievance process.

The WECHU, in its response to COVID-19 within the communities of Windsor and Essex County has:

  • Redeployed staff as considered appropriate to facilitate our response to the pandemic;

Date:   June 30, 2021                    

Signature(s):   

Nicole Dupuis, Chief Executive Officer
Lorie Gregg, Director, Corporate Services
Dan Sibley, Director, Human Resources

  1. Period covered by this report:  July 31, 2021 to September 30, 2021
  2. For the period covered by this CEO Quarterly Compliance Report:
    1. The undersigned has personal knowledge of the matters herein reported or has made due inquiry with respect to the same.
    2. Except as reported in any previous CEO Quarterly Compliance Report, the undersigned reports as follows:
      1. that the Health Unit has been in material compliance with all laws, regulations, orders, judgments or decrees applicable to it.  Without limiting the generality of the foregoing the Health Unit is current in respect of all tax and related withholding and remittances required by law;
      2. the Health Unit has been in material compliance with its By-laws;
      3. the Health Unit has been in material compliance with all other Board resolutions;
      4. the Health Unit has been in material compliance with all contracts and commitments to which the Health Unit is a party including without limitation all funding and accountability agreements;
      5. the Health Unit is current with respect to the payment of all remuneration (including salary and benefits) to its employees;
      6. there are no material variances between what is contemplated by the Operational Plan and what in fact transpired or appears likely to transpire
      7. more specifically, no material changes are required in respect of financial resource allocation plans to address shifts in need and capacity
      8. no material adverse change has occurred in the operations of the Health Unit or its assets and liabilities taken as a whole
      9. there have been no material breaches of the Ethics Code of Conduct by anyone who is subject to it;
      10. there have been no unplanned terminations of any Health Unit employees;
      11. there have been no claims made pursuant to any insurance policies maintained by the Health unit; and,
      12. nothing has come to the attention of the undersigned which would materially adversely change any previous CEO Quarterly Compliance Report,

      except as detailed below:
      Items (vi), (vii), and (viii) have been revised due to the COVID -19 pandemic as follows:

On March 17, 2020, the Province of Ontario enacted the Emergency Management and Civil Protection Act, R.S.O. 1990, c. E.9. (“the Act”), to support efforts to contain the spread of COVID-19, in our communities.  The Act supports public health units to, regardless of their collective bargaining agreements, suspend services, redeploy staff as deemed appropriate, modify hours of work, cancel and or defer vacations, utilize part-time/contract staff to perform the duties and responsibilities of bargaining unit staff and suspend the grievance process. 

The WECHU, in its response to COVID-19 within the communities of Windsor and Essex County has:

  • Redeployed staff as considered appropriate to facilitate our response to the pandemic;

Date: September 30, 2021

Signature(s):

Nicole Dupuis, Chief Executive Officer