How Ontario could slow its growth in COVID-19 cases

With Ontario reporting its highest daily number of COVID-19 cases since early May on Tuesday, there are mounting calls for the government to take more actions to slow the spread of the virus now, in an effort to avoid a full-scalelockdownlater.

The province is facing rapid growth in coronavirus infections. The average number of new cases reported daily over the past week was 383, double what it was just nine days earlier. The daily case count has exceeded 400 on four of the past five days, though the number dropped to 335 on Wednesday.

"The premier and I are both very concerned about the rapid increase in numbers, as I know the people of Ontario are, but we do have a plan," Health Minister Christine Elliott said Tuesday.

But Elliott and Premier Doug Ford did not announceany new public health measures on Tuesday to try to rein in those numbers.

They did unveilone element of Ontario's promised COVID-19 fall preparedness plan the province's upcoming flu vaccination campaign.The government intends to roll out the rest of its fall plan piece-by-piece over the coming days. The ostensible reason for the gradual reveal is that the plan is so big that the public wouldn't be able to absorb it all at once.

"This is a massive, massive plan and very robust. It's jammed with items. If we lay it all down at once, the message isn't going to get out to the people," Ford told his daily news conference.

"We know that a second wave is coming," Ford said. "What we don't know is how bad it will be, how hard we will get hit, because that's up to all of us."

Many public health voices say the second wave is already here. And to reduce how hard Ontario gets hit, they're saying public health measures needto be strengthened immediately.

"What we see are exponentially rising case counts," said Dr. David Fisman, epidemiology professor at the University of Toronto's Dalla Lana School of Public Health."That's what was going to happen in September if you didn't snuff this out over the summer."

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At the current rate of spread, Fisman forecasts that Ontario is on track to see 1,000new cases a day within four weeks unless prevention measures are improved.

"That is going to mean more and more sick people, faster and faster and faster, which is why you have to get ahead of this by taking action now," Fisman said in an interview. "You have to do it proactively, or else you're going to wind up closing the whole economy down in October or Novemberbecause we're going to have a catastrophic event on our hands."

Dr. Irfan Dhalla, vice president of physician quality at Unity Health, which includes St. Michael's and St. Joseph's hospitalsin Toronto, says what's needed is "not about any one particular measure,it's really about government and public health authorities picking a suite of measures."

So, what can Ontario do? There's some consensus among independent experts in epidemiology and public health on what the priorities should be.

Stop indoor service at bars, restaurants

So far this month, the only pandemic restrictionthe government has tightened is the limiton private social gatherings, shrinkingitto 10 people indoors and 25 outdoors, first in Toronto, Ottawa and Peel Region, then across the province. That prompted questions: if it's not safe to have more than 10 people in a house, why is it safe to gather with far more people indoors in a bar or restaurant?

"Indoor service and bars and restaurants is a very important driver [of COVID-19 transmission]," said Fisman

"Given how quickly cases are rising at this point, it does make sense to close down indoor dining and bars, maybe gyms as well," said Dhalla.

Epidemiologist RaywatDeonandan also says bars should be closed, and likely restaurants too, but they should be allowed to offer patio dining as well as take out and delivery.

"Enacting stricter measures does send the message that this is an emergency and we should take it seriously," Deonandan said in an interview. "We don't want people putting their lives on hold for the next six to nine to 12 to 24 months. We want them to live their lives, but with restrained behaviour."

Help people reduce contact with others

"Canada is at a crossroads and individual action to reduce contact rates will decide our path,"the Public Health Agency of Canada said on Tuesday in a newly published documentpredicting the trajectory of the pandemic this fall."If we maintain our current rate of contacts, the epidemic is forecast to resurge."

Life in Ontario right now, in Stage 3 of the province's COVID-19 pandemic plan, is a lot like normal life, but with masks and more lineups. As such, people are coming in contactwith others far more often than in earlier phases of the pandemic.

That's likely part of the reason why public health officials are unable to pinpoint where more than half of Ontario's active cases contracted the virus.

"Transmission of communicable diseases is very much a function of how much contact we have with each other," said Fisman. He said the premier "has at his disposal a lot of policy levers that he can use to reduce the effective numbers of contacts between people in Ontario."

That means making sure everyone who can workfrom home does so.It also means acknowledging how the pandemic has disproportionately hit people on low incomes and communities of colour, many of whom live in crowded housing, rely on crowded public transitand work in places where they come in contact with a lot of people.

"Some demographics are in a tough bind and they want to do the right thing, but they simply can't. And they're being blamed unfairly for this," said Deonandan.

Improve communication

Right now, Ontario's communications strategy seems to involveofficials pleading with people to practise physical distancing and Ford chastising young people for holding what he calls "wild parties."

Deonandanis concerned there's too muchfinger-wagging and not enough compassion.

"We're fond of talking about the stick, scolding, deploying the law with criminal penalties," he said."But we haven't talked about what is in it for people to behave appropriately and what's the incentive to follow the rules."

Ottawa's medical officer of health on Tuesday imposed a strict new order, requiring self-isolation for a wide range of people: anyone who either tests positive for COVID-19,is a close contact of someone who has tested positive; has symptoms of the illness, or is awaiting a test result. The consequence of breaching the order is a fine of up to $5,000 per day.

"We need to find better ways to communicate with peopleto understand the real risks of COVID, not only for their loved ones, but for themselves as well," said Dr. Andrew Boozary, executive director of health and social policy for Toronto's University Health Network.

Go back to Stage 2?

In Stage 2 of Ontario's COVID-19 reopening plan, bars and restaurants servedonly outdoors, cinemas and gyms were closed, along with casinos and convention centres. That's how the province functioned from mid-Junethrough late July, when the case count was trending from 200 down to 100 per day.

The government has indicated it's reluctant to roll back all the way to Stage 2.In the face of that, public health experts say the province needs to make hard choices anddecide what's most important.

The principle they recommend: Close down the indoor operations of businesses that are at higher risk of transmission but are not so crucial to the overall economy, in an effort to keep open everything that is crucial to the economy, including schools.

"The signal you give to the public when you say these spots are open for business is that it's OK to go and gather," said Boozary. "We all want the economy to be back. But if we don't get the virus under control, the economy will continue to suffer."

With the daily numbers of hospitalizations and deaths starting to rise in Ontario, the pressure on the governmentto act quickly is rising too.

"We aren't at the numbers [of deaths]that we were seeing in the spring, and that's a blessing," said Dhalla.

"But there are still people dying of this virus every day," he said. "Behind those numbers are people with lives, people with loved ones. And those of us who work in health care are worried that we will see even more people die over the weeks to come."