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It’s been 28 days, and Toronto is scheduled to reduce restrictions. What are five key indicators telling us?


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It’s been 28 days, and Toronto is scheduled to reduce restrictions. What are five key indicators telling us?

It’s been a month. So how exactly is Toronto doing?

On Oct. 9, Toronto entered modified Stage 2 restrictions, closing high-risk venues to try to control the city’s fast-rising second wave of COVID-19 infections. The measures were supposed to last 28 days, but the city asked for more time, extending the slate of controls until the end of this week. Monday marked exactly a month of modified Stage 2.

In the meantime, the Ford government released a new colour-coded framework for implementing and removing new restrictions. On Saturday, Toronto is scheduled to move from the current slate of restrictions to the province’s “orange” level of intermediate measures. As proposed, the switch would reopen indoor dining, bars, and gyms, with capacity limits and liquor curfews.

Days away from this deadline, the Star examined five important indicators to see how Toronto fared over the last several weeks and how strong a grip the pandemic has on the city.

Weekly cases per 100,000

On Monday, Toronto notched another grim milestone: a jump of more than 500 new COVID cases in one day. The city recorded almost 1,350 confirmed cases in just three days.

“These case count numbers are the most concerning I have seen here in Toronto since the pandemic started,” medical officer of health Dr. Eileen de Villa said at a press conference Monday.

“I don’t think the current case counts point us towards relaxing the roadblocks we’re putting up in front of the virus,” she added, saying the city was in conversation with the province and would release an update Tuesday for how restrictions would evolve.

Single-day numbers can be misleadingly high or low, so health experts prefer to compare the average number of new cases over a week. And to compare between regions with different populations, they typically compare the number of new cases per 100,000 residents.

On Oct. 9, when Toronto entered modified Stage 2, the city had logged 64.4 cases per 100,000 over the previous week, according to the Star’s ongoing tally. On Monday, that number hit 94.5.

Clearly, cases in Toronto are still rising. That doesn’t mean the 28 days of restrictions achieved nothing. In Toronto, the case curve went from double-black-diamond steep over much of September to more of a bumpy bunny hill in the month of October. (A late-September restriction on restaurants may have also helped.)

In mid-October, the province’s science advisory table, a group of experts and health leaders, recommended introducing new public health measures for any region with more than 25 weekly cases per 100,000 residents.

When the Ford government released a colour-coded framework for implementing and removing restrictions last week, the threshold for the red “control” zone was set at more than 100 weekly cases per 100,000 — far higher than what Toronto was seeing four weeks ago, when it introduced the measures that are now scheduled to be lifted on Friday. Toronto is set to enter the “orange” level of intermediate restrictions.

The province said its framework would provide transparency while implementing a gradual approach that avoids total lockdowns. Epidemiologists and infectious diseases experts harshly criticized the framework, saying the measures it introduces would be too little, too late.

“If you apply the framework as is, there is a 100 per cent chance we won’t get better,” Dr. Isaac Bogoch, an infectious diseases specialist at the University of Toronto, told the Star last week. “We may stay the same, but nobody will be surprised if we get worse.”

But case counts alone are not enough to assess the state of an epidemic — these numbers are highly influenced by how much testing is happening and who can get tested.

Testing

In October, Toronto saw a startling 158 per cent increase in COVID-19 cases compared to September. But testing in the Toronto region barely rose by just 1.5 per cent, with 203,145 tests in September compared to 206,279 in October.

“The number of tests we need to perform (is) definitely substantially higher,” said Dr. Andrew Morris, an infectious diseases specialist with the Sinai Health system.

“It just reflects the lack of an effective ‘test, trace, isolate’ strategy. It’s really disconnected.”

From an epidemiological perspective, testing should have more closely tracked the surge in new infections that we saw in Toronto, Morris said.

But barriers — like the shift to appointment-only testing in early October and confusing changes to testing criteria — likely had a countervailing effect, causing the number of tests to flatline even as new cases surged, he said.

“We know there’s much more COVID,” said Dr. Jeff Powis, medical director of infection prevention and control at Michael Garron Hospital. “They’re just not seeking testing.”

The fact that tests in Toronto slightly increased last month is of little comfort to Powis, who questions how many of those tests were done at COVID assessment centres. At Michael Garron’s testing site, swabs have dropped by about 50 per cent since the move to appointment-only testing, he said.

He suggests that a lot of October’s tests may be linked to outbreaks, which have increased significantly in recent weeks. When a nursing home is in outbreak, residents and staff will be tested repeatedly and hospitals are also now testing more patients on admission in hopes of keeping outbreaks at bay, he said.

“I suspect a lot of (October’s testing) was being driven by people trying to control outbreaks or prevent outbreaks,” he said.

It’s unclear how many of October’s tests were also conducted at mobile testing sites, which were significantly ramped up last month to try to help communities that have been disproportionately affected by the pandemic but have stubbornly low testing rates. Ontario Health, the agency in charge of COVID testing, was unable to provide this figure by the Star’s deadline.

Powis said the recent dropoff in swabs collected at his hospital’s assessment centre after the switch to appointment-based testing was motivation to push for a more targeted testing strategy in Michael Garron’s catchment area. Together with East Toronto Health Partners, five mobile testing sites have recently been launched in the city’s east end. Other hotspot areas in the city, like the northwest corner and Scarborough, are also making efforts to ramp up testing in areas showing signs of trouble.

While October managed to avoid the nightmarish testing backlogs that plagued September, experts like Morris worry the province’s testing system is once again at risk as case counts continue to rise. “We are not that far away from overwhelming the testing system again,” he said. “Not because of unnecessary tests, but just because of the sheer volume of infected people. It’s a real problem.”

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Positivity rates

Rising case counts and flatlining testing numbers have led to a predictable surge in another worrying indicator: test positivity rates, which refers to the percentage of tests that come back positive for COVID-19.

For the city as a whole, the lab test positivity rate was 1.3 per cent at the beginning of September. It rose to 3.1 per cent by the week of Oct. 4, when the city entered Stage 2 restrictions, and is now at 4.8 per cent, according to the most recent available data.

Toronto Public Health’s goal is to stay below three per cent; anything above that is considered by many jurisdictions to be cause for concern. But the citywide average also masks far more worrying numbers in certain areas and age groups.

In early October, Toronto Public Health began reporting test positivity rates broken down by neighbourhood. The week of Oct. 4, no neighbourhoods were above 10 per cent test positivity, but three were close.

These testing maps have only grown more worrisome. For the week of Oct. 18, the last week of complete data available, 10 neighbourhoods had test positivity above 10 per cent. Eight of those are in the northwest of Toronto, by far the hardest-hit region of the city in the pandemic so far. Two are in east Toronto, in south Scarborough and Thorncliffe Park.

Breaking the citywide rate down by age groups shows similarly worrisome trends. Torontonians aged 10 to 19 have the highest test positivity of any age group, at over 10 per cent, according to provincial data. Next-highest is the 20-29 age group, at almost nine per cent. Test positivity in 80-plus-year-olds in Toronto sits at 7.9 per cent; four weeks ago it was at 2.3 percent.

The rise in this oldest age group is the most concerning shift. Because this demographic is the most at risk for severe COVID-19, health experts have highlighted “spillover” in infections from younger age groups to older ones as a major threat to health-care system capacity.

Hospitalizations

Over the last several days, Anthony Dale, CEO of the Ontario Hospital Association, has been on the phone with hospital officials. And the message he’s heard is loud and clear: “No one feels comfortable lifting public health measures in the city of Toronto.”

He acknowledges that current hospital numbers may not paint an overly alarming picture to the general public. According to OHA data, Toronto-area hospitals had an average of 188 COVID-19 hospitalizations last week, and large hospital corporations like Sinai Health, Michael Garron and Sunnybrook Health Sciences Centre had fewer than 10 each.

But snapshot statistics like these fail to capture deeper pressures across the system, which last week showed its first sign of cracking when a surge at William Osler Health System forced the hospital to cancel some elective surgeries and transfer patients to other health centres.

As COVID cases rise, there are fears that William Osler’s experience could be a harbinger of what’s to come. Hospitals are already stretched thinner by worker shortages, a backlog of procedures and increasingly frequent COVID outbreaks.

“Right now hospitals are fighting at 100 per cent occupancy, their labs are running 24/7, they’re playing catch-up on 150,000 surgeries that were cancelled in wave one,” Dale said. “It’s the illusion of stability right now. But beneath the surface, you look at the system as a whole, the trends are going all in the wrong way.”

COVID hospitalization numbers are also a lagging indicator because they reflect what was happening in the community a number of weeks prior, Dale said. As other jurisdictions have seen, the disease is “lightning quick” — hospitals can rapidly go from quiet to overwhelmed.

And some in Toronto’s hardest-hit areas are starting to feel the burn. In Toronto’s northwest corner, Humber River Hospital has seen a slow but steady uptick in patients since late September, said infectious diseases physician Dr. Ian Brasg.

“What we’re seeing around the city, with hospitals needing to cancel elective surgeries — these are indicators of stress on the system,” he said. “To be opening up now in that context is very concerning.”

On the other side of Toronto, COVID hospitalizations have quadrupled over the last month at Scarborough Health Network, which currently has 75 patients across the hospital’s three sites.

That’s “about 20 per cent of the province’s admissions,” according to chief of medicine Dr. Elaine Yeung.

“The numbers are definitely higher than the first wave,” Yeung said. “We are worried … we haven’t had to cancel elective surgeries at this point, but we’re watching things very, very closely.”

LTCs

Nursing homes were devastated in the pandemic’s first wave. By mid-summer, long-term-care residents represented two-thirds of Ontario’s total COVID deaths.

In September, eight Toronto long-term-care homes declared an active outbreak, according to ministry data. In October, 26 did. Perhaps most worrying, another seven have declared outbreaks in November, almost as many as the whole month of September though only nine days have elapsed.

An active outbreak can be declared after just one lab-confirmed COVID case in a resident or staff, and many of these have been small. But some have grown to the same sickening proportions as we saw in the spring.

In September, two Toronto LTCs had outbreaks that infected over 40 residents. In October, five had outbreaks that large. It’s difficult to calculate exactly how many deaths resulted, because the ministry does not report exact numbers for any totals lower than five. But at least 50 residents died across both months combined.

The province promised to gird nursing homes by creating more beds and hiring more staff, among other measures.

A study that geriatrician Dr. Nathan Stall co-authored in August showed that the risk of a long-term-care outbreak was strongly linked to case numbers in the surrounding community.

Responding to the province’s colour-coded framework — and its “red” zone threshold of over 100 weekly cases per 100,000 — Stall wrote that “Allowing this level of transmission will have catastrophic consequences for our (long-term-care) population.”

Jennifer Yang is a Toronto-based health reporter for the Star. Follow her on Twitter: @jyangstar

Kate Allen is a Toronto-based reporter covering science and technology for the Star. Follow her on Twitter: @katecallen

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