Purpose: To present an overview of recent trends in COVID-19 cases within the province of Ontario and provide evidence-based recommendations on best practices for limiting the impact of COVID-19.
Background: On March 11th 2020, the World Health Organization declared COVID-19 a global pandemic . Since then, the number of COVID-19 cases and deaths have been increasing rapidly worldwide. As of May 24th, 2020, there have been 84,697 confirmed COVID-19 cases and 6,514 deaths in Canada . Ontario has had 25,297 confirmed cases overall and 2,164 deaths . In Ontario, a Declaration of Emergency was announced on March 17th in order to protect the public. This declaration has led to the closure of businesses and public facilities, as well as the introduction of physical distancing measures to reduce spread of the virus. The declaration remains in effect to this day (May 25th 2020).
In recent days, Ontario has experienced a steady rise in daily reported COVID-19 cases. On May 22nd, there were 441 reported cases, with a 5-day rolling average of 425.3 cases. Since May 10th, the number of daily cases has been steadily increasing, going from a low of 294 cases to 427 cases just 9 days later. While this is lower than the peak of daily cases of 640 on April 24th, trends show a steady rise in the last 2 weeks (see Appendix A) . These trends are alarming and require immediate action to prevent future peaks in cases.
Testing capacity has increased dramatically in Ontario throughout the COVID-19 pandemic. On April 13th, a total of 109,764 COVID-19 tests had been completed, which compares to 591,377 tests completed by May 24th . While the province has been testing at rate of 4019.7 tests/ 100,000 people, Ontario has not been reaching the goal of completing 16,000 tests/day; instead Ontario has been conducting less than 12,000 tests/day since May 16th . The decline of tests complete can be seen in Appendix B below. The Ministry of Health has previously stated that it has the capacity to conduct at least 20,000 tests a day , but Ontario has failed to meet this number since the beginning of the pandemic.
Regarding daily deaths in Ontario; 119 deaths were reported on May 4th, representing the highest number of daily reported deaths . When we compare this to 24 reported deaths on May 24th, it reflects an observable downward trend in COVID-19 related deaths2 (Appendix C).
In terms of population demographics:
41.1% of all cases are >60 years of age
3.2% of all cases are <19 years of age
25.1% of all causes are between the ages of 20-39
30.5% of all cases are between the ages of 40 and 59 [3,4]
60.6% of cases are a result of close contact with a confirmed case or outbreak associated, and 12.8% are a result of sporadic community transmission, calling for an increased need and refinement of contact tracing efforts  (Appendix D). The Greater Toronto Area public health units account for 68.4% of all cases in Ontario , suggesting that efforts must be concentrated in these communities.
As of April 16, 2020, the Ontario government has considerably expanded hospital capacity to prepare for COVID-19 patient needs. More than 1,000 acute care beds and 1,492 critical care beds have been added to hospitals . Of the total critical care beds, 2,811 are equipped with ventilators, which compares to only 1,319 that were equipped when the outbreak began . The Provincial Government has also taken steps to ensure that hospitals have sufficient staff available by redeploying surgical nursing staff to work within clinical units, sharing emergency department and intensive care nursing staff across units, sharing physician resources across hospitals in a given region, recruiting family doctors to complete shifts within the hospital, and recruiting healthcare retirees .
Although Ontario has been taking steps in the right direction to ensure hospitals are equipped for COVID-19 patients, it is important to note that most of these changes were made in mid-April. With the phase-1 reopening of the economy in Ontario and the public not strictly adhering to physical distancing guidelines, the adaptive changes made are likely not enough for the surge in cases that occurred over the last week. Thus, it is questionable whether current hospital capacity truly reflects adequate healthcare need.
Another impact of COVID-19 is the decreased rate at which individuals are visiting hospital emergency departments . One patient was reported to have endured a stroke that paralyzed one of her arms, waiting 12 hours before seeking medical attention . Emergency physicians have reported very low patient numbers, as evidenced by a 44% drop in emergency department visits between March 11 and April 30 compared to previous years . Those that do show up are considerably more ill after trying to overcome their ailments by themselves at home . There is a dire need for public health campaigns that emphasize that urgent care should not be avoided out of fear of COVID-19, while ensuring that hospitals are taking appropriate measures through PPE utilization and sanitization. Patients should be encouraged to seek care in order to avoid complications or medical states that may put their lives at risk.
The Ontario government has made several amendments to its policies in response to COVID-19 trends; however, the success and efficacy of these changes is yet to be seen. Initially, testing restrictions limited testing eligibility to select groups of individuals. The province even delivered a plan to test individuals belonging to vulnerable groups on April 23, including those in homeless shelters and Indigenous communities .
However, as cases have risen, Premier Doug Ford stated that a detailed testing strategy would be released the week of May 25 . This strategy will aim to make testing open to anyone, whether one is symptomatic or not, to ensure that people are aware of their COVID-19 status and can take appropriate actions to prevent spread .
Furthermore, the Ontario government has developed a comprehensive framework to assist hospitals in assessing their readiness and planning for resumption of surgeries and procedures while maintaining capacity for needs of COVID-19 patients . This plan will vary from hospital to hospital, depending on the dynamics of the communities they serve . Some hospitals have also been assigned temporary management of long-term care homes if they have been unable to contain the spread of COVID-19 in their facilities .
On April 27th, the province released a framework to allow for the reopening of certain sectors of the economy based on their ability to contain the spread of the coronavirus . This framework breaks the reopening of the economy into 3 stages, with a 2-4 week gap between stages in order to monitor for virus outbreaks:
Opening select workplaces that can immediately meet or modify operations to meet public health guidance and occupational health and safety requirements (e.g., curbside pick‑up or delivery)
Opening more workplaces, based on risk assessments, which may include some service industries, and additional office and retail workplaces
Opening all workplaces responsibly
Stage 1 began on May 19th, 2020. The purpose of the reopening is to ensure that Ontario’s economy can operate at some capacity while still limiting the spread of the virus.
School closures are another measure which the government has taken to reduce the spread of COVID-19. All public schools in the province have been closed since March 12, and it was recently announced that school closures would remain in effect for the remainder of the school year .
Going forward, it is critical to evaluate recently implemented policies in conjunction with health information and the strategies other countries have employed to determine next steps. While Ontario has made several strides to combat the ongoing COVID-19 pandemic, there are many areas for improvement that must be addressed.
Increase capacity for testing
One strategy that is needed is widespread testing. Previously, restrictions on testing prevented many from being tested unless they fell into a specific group and met many symptom requirements. However, a broad testing strategy that permits everyone, including asymptomatic individuals, to get tested is needed in order to recognize who may be carrying COVID-19 and prevent them from perpetuating transmission. The benefits of widespread testing can be seen in South Korea . The two pillars of their COVID-19 response are testing and tracking, which have allowed the nation to flatten the exponential spread of COVID-19 . With low-contact screening clinics and wide availability of test kits, South Korea was able to conduct 15,000 daily tests as early as February 28, which exceeds Ontario’s current testing rates . Therefore, Ontario needs to leverage its testing capacity in conjunction with advanced contact tracing in order to control transmission and provide proactive care.
Improve physical distancing measures
As the weather gets warmer, more people may be inclined to gather in outdoor spaces, as demonstrated by an estimated 10,000 people who attended Trinity Bellwoods Park on May 23rd. Therefore, greater precautions should be taken to avoid possible transmission in public spaces. Increased signage, enforcement of physical distancing, or designated areas for small group gatherings should be explored. Currently, sporadic community transmission accounts for 12.8% of acquired cases  and poor safety precautions in stores threaten to increase community transmission as Ontario begins phase-1 of reopening.
Re-opening of several establishments have been occurring, garnering hundreds of people going in and out of stores. Proper precautions should be undertaken by store owners, and consequences given to establishments who do not comply with public health advice. Hand sanitizing stations, requirement of gloves or masks for customers or workers, and the option for curbside pick-up/delivery should be offered in order to prevent outbreaks at local establishments.
Improve messaging towards younger populations
Many cases of COVID-19 fall below the age of 60, implying that those in younger demographics need to take physical distancing and precautions more seriously. 25% of the total case burden is in individuals between the ages of 20-39. As the weather gets warmer, younger demographics may feel the urge to visit their friends outdoors. In a study done by Stanford University, individuals aged 18-31 had the lowest rate of compliance to phyical distancing protocols . Compared to other age groups, only 52.4% of individual’s from this demographic practiced physical distancing, whereas more than 60% of other demographics followed guidelines . Common rationale within this demographic involved concerns about mental and physical health, the belief that other safety precautions (such as hand-washing) were sufficient for protection, and for some, the belief that society is overreacting .
Public health campaigns or policies should be implemented to better capture this demographic, as they are still vulnerable to transmission. Additionally, messaging towards the younger demographic should involve information regarding their concerns of physical and mental health, as well as dispelling confusion about safe practices.
Ensuring coordination of Health Systems and Services
The European region office of the World Health Organization released a document to ensure that Governments are using the most effective methods to mobilize Health systems in response to COVID-19. The 16 recommendations (see Appendix E) have been formulated reflecting the characteristics of COVID-19 and based on successful evidence informed practices. The actions taken in Ontario should take the form of a coordinated plan, encompassing all health services, as opposed to piecemeal actions taken in response to individual factors.
5- Day Rolling Average as of May 25: 425.3
Cumulative cases as of May 25th: 25,297
Number of COVID-19 tests completed and percent positivity: Ontario, March 29th, 2020 - May 23rd, 2020
Number of COVID-19 Daily Deaths reported for Ontario since May 4th, 2020- May 25th, 2020
Confirmed cases (n=25,904) of COVID-19 by likely source of acquisition: Ontario, January 15, 2020 to May 24, 2020
Summary of 16 Health System Recommendations to respond to COVID-19 (Retrieved from: http://www.euro.who.int/__data/assets/pdf_file/0003/436350/strengthening-health-system-response-COVID-19.pdf?ua=1)
1- WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. (2020, March 11). Retrieved May 25, 2020, from https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-COVID-19---11-march-2020
2- Tracking the spread of coronavirus in Canada and around the world. (2020). Retrieved from https://newsinteractives.cbc.ca/coronavirustracker
3-Tsekouras, P. (2020, May 24). Ontario records another spike in new COVID-19 cases. Retrieved from https://toronto.ctvnews.ca/ontario-records-another-spike-in-new-COVID-19-cases-1.4952266?cache=yesclipId104062?clipId=89925
4- Ontario Agency for Health Protection and Promotion (Public Health Ontario). Epidemiologic summary: COVID-19 in Ontario – January 15, 2020 to May 24, 2020. Toronto, ON: Queen’s Printer for Ontario; 2020
5- Ontario Significantly Expands Hospital Capacity to Prepare for Any COVID-19 Outbreak Scenario. (2020, April 15). Retrieved May 25, 2020, from https://news.ontario.ca/opo/en/2020/04/ontario-significantly-expands-hospital-capacity-to-prepare-for-any-COVID-19-outbreak-scenario.html
6-Mendleson, R., Ogilvie, M., & Bailey, A. (2020, May 24). Where have all the patients gone during COVID-19? Not to the ER. Star analysis reveals stark, nationwide trend. Retrieved May 25, 2020, from https://www.thestar.com/news/canada/2020/05/23/fear-of-COVID-19-keeping-canadians-out-of-emergency-rooms-star-analysis-shows.html
7- COVID-19 action plan: protecting vulnerable Ontarians. Government of Ontario. Retrieved May 25th, 2020, from https://www.ontario.ca/page/COVID-19-action-plan-protecting-vulnerable-ontarians
8-Ford says Ontario needs to begin testing 'everyone possible' for COVID-19. (2020, April 8). Retrieved May 25, 2020, from https://toronto.ctvnews.ca/ford-says-ontario-needs-to-begin-testing-everyone-possible-for-COVID-19-1.4888093
9-Ontario Releases Plan to Resume Scheduled Surgeries and Procedures. (2020, May 7). Retrieved May 25, 2020, from https://news.ontario.ca/opo/en/2020/05/ontario-releases-plan-to-resume-scheduled-surgeries-and-procedures.html
10-Ontario Takes Steps to Better Protect Long-Term Care Residents and Staff During the COVID-19 Outbreak. (2020, May 13). Retrieved May 25, 2020, from https://news.ontario.ca/opo/en/2020/05/ontario-takes-steps-to-better-protect-long-term-care-residents-and-staff-during-the-COVID-19-outbrea.html
11-A Framework for Reopening our Province. Government of Ontario. Retrieved May 25, 2020 from https://www.ontario.ca/page/framework-reopening-our-province
12 - Health and Safety Top Priority as Schools Remain Closed (2020, May 19). Government of Ontario. Retrieved May 25,2020 https://news.ontario.ca/opo/en/2020/05/health-and-safety-top-priority-as-schools-remain-closed.html
13- Lee, D., & Lee, J. (2020). Testing on the Move South Korea’s rapid response to the COVID-19 pandemic. Transportation Research Interdisciplinary Perspectives, 100111.
14-Moore, R. C., Lee, A., Hancock, J. T., Halley, M., & Linos, E. (2020, January 1). Experience with Social Distancing Early in the COVID-19 Pandemic in the United States: Implications for Public Health Messaging. Retrieved May 25, 2020, from https://www.medrxiv.org/content/10.1101/2020.04.08.20057067v1
#COVID19 #PublicHealth #Prevention #PhysicalDistancing #Health #CommunityHealth #Evidence #Policy #Research