Shift in virus battle plan rattles medical field
This week Ontario suddenly and completely shifted its pandemic strategy. It decided to prioritize opening businesses, and keeping them open, no matter what. It decided to play to hospital capacity, and let COVID-19 run. It’s not herd immunity, but it’s not far from herd immunity with seatbelts.
“No, we haven’t arrived at a stage of acceptance,” Dr. Barbara Yaffe, Ontario’s associate chief medical officer of health, said Thursday. “Government is trying to balance the control of the disease, and the severe impacts that can result from the measures taken to control the disease. So it’s a careful balance.”
“If you apply the framework as is, there is a 100 per cent chance we won’t get better,” said Dr. Isaac Bogoch, infectious diseases specialist at the University of Toronto. “We may stay the same, but nobody will be surprised if we get worse. If they recalibrate this, though, we could see a decline in cases, with an improved test-trace-isolate coming in the next 60 days.”
Setting a clear framework, after months of gut-based decisions based on completely opaque public health advice, is laudable.
But the thresholds the government set that could actually trigger meaningful intervention are so sky-high as to be almost meaningless: A new case rate of 100 per 100,000 per week, which has been exceeded just twice by any jurisdiction in Ontario since testing ramped up; A test positivity of 10 per cent, which on any reasonable test volume is the virus out of control; Hospital capacity at risk of being overwhelmed, and public health capacity at risk or overwhelmed.
“When you look at it, we will need to be very careful,” says
Dr. Peter Juni, the scientific director of Ontario’s science table, a professor of medicine and epidemiology at the University of Toronto, and the director of the Applied Health Research Centre at St. Michael’s Hospital. “The point is, you know, if this thing starts to accelerate you know that you need to step on the brake anyway.
“If we just left it at that and we say that’s now our framework, and we’re good to go, I do not think it will work out.”
Juni thinks about the harm of restrictions, and says he knows the government needs to strike a balance between its competing responsibilities. But his scientific advice is that the thresholds to restrain the virus would be significant restrictions — the closing of indoor spaces — should be closer to a five per cent positivity rate, and 50 cases per 100,000 people per week. That would keep Peel in Stage 2, and Toronto would be close.
So who authored this plan? The science table was not consulted. The provincial projections presented Oct. 29 showed an avoidance of a worst-case scenario, and showed Ontario’s path following Michigan’s. Ontario’s curve hadn’t flattened, but growth was slowing. Premier Doug Ford seemed excited, though he misinterpreted the data.
But it was based on Ontario’s numbers with restrictions in place. The modelling indicates cases will now rise.
“We need to reset the assumptions in the models,” said Dr. Steini Brown, the head of the science table and the dean of the Dalla Lana School of Public Health at the University of Toronto. “It’s a little challenging to figure out who we look like now.”
The province didn’t ask Ontario’s geriatrics community. Dr. Samir Sinha, the director of geriatrics at Mt. Sinai and the University Health Network, blasted it. Dr. Nathan Stall, a geriatrician at Sinai Health System, compared it to the Great Barrington Declaration, which was a herd immunity document that posited, with no evidence, that vulnerable parts of the population could be protected if societies reopened with no restrictions. He’s not wrong.
“It’s a pretty similar strategy,” Stall saud. “It’s a Great Barrington-esque plan.”
The province didn’t ask the hospital community. “I don’t think the province understands how much pressure (hospitals) are under right now,” said one source in Ontario’s medical community with knowledge of the hospital situation. “This is the single biggest mistake of the pandemic.”
No, this belongs to the health measures table, which consists of seven current or former medical officers of health, and is responsible for reopening and restrictions. It belongs to Dr. David Williams, the chief medical officer of health. And it belongs to Doug Ford, whose public statements indicate he does not understand it, and his government.
On Oct. 15, the science table published its research on restrictions. It showed a gradual shift of the disease into older, more vulnerable age groups was highly likely, and in fact that is happening now.
It showed rising case numbers in long-term care and the deaths that follow, and are following.
It showed how hospitalizations would eventually rise, as they have in other jurisdictions, which would force interruptions in clearing surgical backlogs, among other priorities. It showed there is evidence bars and restaurants drive transmission.
That’s why Peel medical officer of health Dr. Lawrence Loh told his council that if business reopens, there needs to be a tradeoff. He proposed a ban on private gatherings, which though unfair and perhaps unenforceable, speaks to the cost of this plan.
“Restaurants are high risk. There’s a reason why every country on earth has put some restrictions in place when their case counts get high, in this setting,” Loh said. “If you’re going to loosen restrictions on venues, you need to come down on some of the other drivers of transmission in our communities.”
With this framework, the only hope is that the province — which has been resistant and slow on second-wave restrictions, whose premier speaks most passionately about the struggles of business owners, and which completely overhauled its strategy with almost no warning — will intervene far short of the benchmarks it has deliberately set in order to let businesses reopen.
Otherwise, harder lockdowns likely await.
“This is always about recognizing the path and when exponential growth starts, and when you start to have doubling times that slowly reach two weeks and then perhaps 10 days, etcetera,” says Juni.
“Then you need to be just really, really careful that you don’t lose track, and you know we see that in Europe. You probably know I’m from Switzerland originally. What happened in Switzerland is heartbreaking, and one of the reasons for that is because there was this disconnect between science and politics, a bit, with a lot of polarizations that I hope we can prevent here.”
Hopefully, it’s not too late.