Tracing COVID’s grim path
Newly released data shows how virus slipped into city, then took hold of most vulnerable populations Officials emphasized ‘we’re all in this together.’ But for some areas of the city, that just wasn’t true
TToronto has been in the coronavirus’s grip g for just over six months, though it may feel like a lifetime. The path of the
virus has twisted wildly: nearly every month has brought a new upheaval.
In July, Toronto Public Health released an important dataset: a catalogue of every case reported in the city since
the first known case in late January, roughly 15,300 total. Identifying details have been removed to protect privacy, but each case includes the person’s age bracket, neighbourhood and source of infection; whether they were hospitalized, in critical care or intubated; whether they recovered, are still fighting infection, and more.
You might think you know the story of COVID-19 and Toronto. But the dataset, wwhich TPH says it released in the in- terest of transparency, contains revelations about how the virus slipped into TToronto and gained a foothold before taking aim at the most vulnerable residents and neighbourhoods. The Star’s aanalysis of this trove of information tells the t untold story of the epidemic’s first wwave — a nightmare that some fear could repeat itself, should the lessons
from this first chapter go unheeded.
TTravel
China. Iran. Italy. In the early days of the pandemic — when infected travellers wwere still the biggest threat — these were tthe countries that drew alarmist head- lines, triggered travel advisories, and influenced who got tested for COVID.
Three countries were indeed responsible for the majority of Toronto’s first travel cases.
But they were not necessarily the countries everyone first assumed. Rather, the top country linked to the earliest travel infections was the United States. Travellers from the U.S. accounted for 37 per cent of travel cases in Toronto between January and March, or 106 people. For weeks before the border closed, the U.S. presented our greatest travel-related COVID threat.
The United Kingdom was the second-biggest contributor, linked to 14 per cent of travel cases. Five per cent came from Iran. Infections from all other destinations, including China and Italy, had fewer than five cases each in these first three months.
“Other countries, including the one south of us (and) the U.K. — none of those were on our radar for high COVID rates,” said Dr. Vinita Dubey, associate medical officer of health with Toronto Public Health. “We now know that people who either went there and came back — or travellers who came from those places — actually played a big role.”
Another hidden trend: who these earliest travellers were, and where they lived. The Star’s analysis shows that a downtown hot spot was already silently emerging by the time lockdown measures started in mid-March, the neighbourhood known as “Waterfront Communities-Toronto Island.”
It includes areas like the Distillery District and Toronto Islands. But most of this community is wedged into a condodense swath between Lake Ontario and Queen Street including the King West entertainment district and the CityPlace condos. The Waterfront neighbourhood skews young and is growing fast, particularly with people in their 20s and 30s.
Looking at the demographics of infections through travel in the Waterfront upends early assumptions that at-risk travellers were ““visiting friends and relatives” returning from countries like Iran or China, Dubey said.
In the Waterfront, 71 per cent of people who were infected through travel are under 40.
These young travellers were following the premier’s instructions. The week before March Break, Premier Doug Ford urged Ontarians to “go away, have a good time.” Over the next two weeks, 16 travel-related COVID cases would emerge in the Waterfront, highest among Toronto neighbourhoods.
To this day, more than four months after the pandemic was declared, the Waterfront has the city’s highest number of travel cases, and the fifth-highest rate for travel cases. (The highest rate, which accounts for population size, is in affluent Bridle Path-Sunnybrook-York Mills.)
The Waterfront neighbourhood is the city’s most populous, with more than 65,900 people as of the 2016 census, so perhaps it’s unsurprising to have many travel cases. Dubey cautions that the number of Waterfront travel cases may have more to do with behaviour.
“Is it related to their age, because they’re younger and more likely to travel? Is it because they’re younger and more likely to engage in certain activities? she asks. “It’s very hard to tease that out.”
It’s unclear what role these younger, downtown travellers played in the city’s overall epidemic. March was a month when every COVID case was leading to 3.5 new infections on average, according to Dubey.
The Waterfront faded as a hot spot when travel ceased to be the primary source of infection in the city. The burden of COVID would shift from the affluent downtown core to poorer areas on the edges of Toronto.
Community spread In the U.S. in late February, COVID cases began appearing in
Americans who had not travelled or been in contact with travellers: an ominous sign. Such cases, with no epidemiological link, indicate the virus is spreading locally, via undetected chains of transmission.
In Toronto, reporters began asking if the city had recorded any of these “community” cases. Dr. Eileen de Villa, Toronto’s medical officer of health, promised to inform residents if any appeared.
On March 6, de Villa said “currently, there is no evidence of local transmission.” On March 12: “We are still not seeing confirmed evidence of local transmission.”
But March 16, she broke the news. Toronto had seen a surge of cases, “some of which are unlinked, and thus indicate community transmission.”
Public health can only act on cases it knows about. De Villa informed the public very quickly after receiving word: the first two cases with a “community” infection source reported to Toronto Public Health were recorded on March 12 and 13; case investigators would have taken some time to rule out other sources. TPH learned of four more community cases March 16, the day de Villa confirmed local transmission. Unbeknownst to public health, however, the situation was far more grave. On Valentine’s Day, a month before de Villa’s announcement, a woman in her 30s in Trinity-Bellwoods started experiencing symptoms. Her case, ultimately attributed to community spread, was not reported to TPH until March 24, a week after de Villa’s remarks.
In total, the city already had nearly 50 cases that would ultimately be attributed to community spread but were not reported to public health until days, weeks and sometimes months after de Villa’s announcement.
The lags between the emergence of these key cases and when they were reported to public health were sometimes gaping. Shortly after the Trinity-Bellwoods case, a 40-something man in Humbermede and a 50-something man in Princess-Rosethorn would catch COVID-19 in the community. These cases were not reported until April 6 and May 29, respectively.
Public health uses a term called “episode date” to estimate when an infection was acquired. If the date of symptom onset is known — and it isn’t always obvious — episode date refers to that. When an estimated date of onset isn’t available, investigators substitute the day the person was swabbed; when that isn’t known, they use the day the case was reported to public health.
For all cases reported to TPH, the gap between episode date and reported date has shrunk over time. In early March, the average was nearly 14 days; in early July, only four days. (These averages exclude cases with a gap of zero days, in which the reported date was used for the episode date.)
Dubey said the delays in reporting cases to public health can have several causes. TPH data from late May suggested it was taking an average of almost five days between when someone presents with symptoms to when they get tested. And in those early months, the province also tightly restricted tests.
Lab turnaround times certainly played a role. Dubey noted that in February and March, a shortage in testing supplies and a testing backlog led to long delays. “Those delays in lab reporting are delays in our case and contact follow-up.”
Lockdown As COVID seized the city in mid-March, officials abruptly shut down schools and non-essential businesses. They told everyone who could do so to stay home. The message was one of unity: “We’re all in this together.”
It wasn’t true. Lockdown protected Toronto’s richest, whitest neighbourhoods, but not the poorest and most racialized ones.
In Toronto’s 20 whitest, richest neighbourhoods — with the lowest percentages of visible minorities and of residents in low-income households, according to the 2016 census — the widespread closures had an immediate and sustained effect. Almost instantly, their curve flattened.
But for the 20 poorest, most racialized neighbourhoods — with the highest percentages of visible minority residents and people in low-income households — lockdown made little or no difference. Cases kept rising, and didn’t begin to trend downwards for two months.
Four in 10 Canadians have a job that can be done from home, according to Statistics Canada. The likelihood of holding such a job is shared unequally: members of lowerearning households are far less likely to be able to work from home than higher-earning households (And visible minorities are more likely to be lowincome earners, other research shows.)
So closing non-essential businesses was more likely to have one of two terrible impacts for the working poor: residents were more likely to lose jobs; or more likely to have to leave home to keep working in “essential” businesses throughout the shutdown, and face that exposure risk.
TPH data released Thursday confirms the pandemic’s terrible inequality. Analyses of this data, collected May 20- July 16, come with limitations, including that 27 per cent of cases did not report sociodemographic information, especially those who were severely ill in hospital, and that case counts reflect biases in who has access to testing.
Nevertheless, the findings are striking. While 48 per cent of the city is white, just 17 per cent of COVID cases are; while 52 per cent of the city belongs to a visible minority group, 83 per cent of COVID cases say the same. People in low-income households make up more than half the cases from this period, but represent less than a third of the city’s overall makeup.
Outbreaks On March 31, epidemiologist Amy Greer shot off an angry tweet: “What sort of muppet show are we running here? I am speechless about this.” Greer, a professor at the University of Guelph, was not the only health expert to react with incredulity to a statement that day from Ontario’s chief medical officer of health, Dr. David Williams.
Williams said health-care workers in long-term-care homes did not need to regularly wear personal protective equipment, such as masks, unless their facility had a COVID outbreak. He claimed that the public health measures already implemented, such as screening staff and quarantining those who recently travelled, would keep residents and staff safe.
It’s impossible to say how much responsibility this policy bears for the horror that followed.
The day Williams made that statement, 10 long-term-care homes in Ontario had reported an outbreak. By the time he reversed course eight days later and ordered universal masking for staff in these facilities, 58 LTCs were in outbreak. As of this week, more than 325 LTCs have an active or resolved outbreak.
Eight LTC staff have died along with more than 1,800 residents.
About 75 of those outbreak-battered LTCs are in Toronto. When mapping outbreak-associated cases — which by TPH’s definition include cases in LTC homes as well as retirement homes, hospitals, shelters and more — this brutal phase of the pandemic escalates quickly in the neighbourhood of Islington-City Centre West, on the
Toronto Public Health data from late May suggested it was taking an average of almost five days between when someone presents with symptoms to when they get tested. And in those early months, the province also tightly restricted tests
western edge of Etobicoke. It’s home to Eatonville Care Centre, a 247-bed facility, where 184 residents were infected and 43 died.
Two neighbourhoods in Scarborough, Rouge and Morningside, follow closely.
These neighbourhoods are home to Altamont Care Centre and Seven Oaks, where 53 and 41 residents have died respectively.
The military was deployed at Eatonville, Altamont, Hawthorne Place and Downsview Long-Term Care Centre in North York, and three other GTA long-term-care homes in late April.
A report from the armed forces the next month said staff at Eatonville could not access key supplies, including wipes, because they were locked up; and cited a “general culture of fear to use supplies because they cost money,” such as gowns and gloves. At Altamont, the military team raised issues of poor infection prevention and control practices with the facility’s leadership, after which “staff advised they will address the deficiencies.”
But though Toronto’s longterm-care and retirement homes are clustered more densely downtown than in outer neighbourhoods, the map of all outbreak-associated cases is the opposite, with regions like the city’s northwest lighting up. The reasons are not entirely clear; homes with serious outbreaks are scattered across the city.
But it could be partly because infected LTC staff who work at a facility in outbreak are recorded by home address, not work address.
Some of Toronto’s hardest-hit neighbourhoods for sporadic (non-outbreak) cases also have the highest percentages of “nurse aides, orderlies, and patient service associates” — a Statistics Canada classification that includes personal support workers and other staff in nursing homes. (In Toronto, immigrants make up 79 per cent of this occupational group.)
Without more data, it’s difficult to say what role the “wildfire” of nursing home outbreaks played in Toronto’s larger epidemic.
Another link is that these outbreaks tied up testing resources for months; the province only started allowing any resident who wanted a test to get one on May 25, after completing a push to test every LTC staff and resident. The city’s sporadic case curve began a sustained downward trajectory five weeks after the outbreak-associated case curve did the same.
Toronto’s hardest-hit corner
In early April, the question was gaining urgency: are some minority groups, especially Black communities, at greater risk in the pandemic? Race-based COVID data would be key to answering that question. But on April 10, when asked if he would collect this information, Williams waved away the idea.
“In Canada, we don’t collect race-designated cases unless there are certain risk factors,” the province’s chief medical officer of health told reporters.
As he spoke, the coronavirus was already gaining a deadly foothold in Toronto’s northwest corner, one of the most racialized and historically marginalized areas. That week, Mount Olive-SilverstoneJamestown, one of Toronto’s Blackest neighbourhoods, saw more people fall sick from COVID than any other Toronto neighbourhood. The following week saw spikes in two other northwest neighbourhoods, including the Jane-Finch community.
By May 6, when Williams reversed course on race-based data, the northwest corner was already Toronto’s hardest-hit region.
Thursday’s data release from TPH reveals that Black people made up the biggest percentage of total cases, 21 per cent; and Latin Americans had the highest infection rates, 481 cases per 100,000 people.
The 19 neighbourhoods with Toronto’s worst infection rates are all in the northwest, home to some of the city’s biggest Black and Latin American communities.
The area’s first documented case was the man in his 40s from Humbermede, who was the second case of communityacquired infection in the city. He developed symptoms March 1, but the case was not reported to public health until April 6.
In the last two weeks of March, new cases began spiking in two northwest neighbourhoods that today have some of the city’s highest infection rates: Downsview-Roding-CFB — which had the city’s highest weekly case counts for much of April — and West HumberClairville in north Etobicoke, which currently has the city’s highest number of infections linked to health-care settings like doctors’ offices or dialysis clinics.
One week after Mother’s Day, which some feared would drive a surge of cases, was actually when Toronto’s epidemic curve for community cases finally peaked and began sloping downwards.
But one northwestern neighbourhood didn’t join the victory ride. In Mount Olive-Silverstone-Jamestown, cases continued a steep climb for two more weeks before peaking. In that time, more than 100 Mount Olive residents were infected.
It’s unclear how closely those numbers are tied to access to testing.
But today, Mount Olive has the highest infection rate of any neighbourhood — 1,308 cases for every 100,000 people. Mount Olive, roughly bordered by Steeles Avenue, the Humber River and Martin Grove Road, is the northwest neighbourhood with the highest concentration of visible minorities and one of the city’s most low-income areas.
Many residents here would not have had the luxury of working from home; Mount Olive has the city’s highest proportion of people who work as cashiers, truck drivers and labourers in plastics manufacturing. Many would have been deemed “essential” through lockdown.
Meanwhile, Mount Olive also has some of the city’s most crowded homes.
Indeed, TPH’s data shows Mount Olive has the highest rate of COVID infections linked to “close contact”— a category often assigned where someone is infected by a household member.
As of Friday, 431 people living in Mount Olive have been infected. By comparison, The Beaches has Toronto’s lowest infection rate, and it’s the third-whitest community. To date, it has had 13 cases.
COVID in kids
One enormous question remains unanswered, even with six months of data on every confirmed case in Toronto: how are kids affected and what role do they play in spreading COVID?
The question is gaining urgency as the days shorten and school draws near. For Dubey, as she mines city data, this is top of mind, especially now that infections are showing up more in younger people.
“One of the trends we’re seeing is more children are getting COVID, but that may be related to more testing of children. It’s hard to know,” she said. “I think that’s one pattern that we need to consider going forward, especially as we talk about schools reopening.”
School closures likely played a major role in reducing infections in people 19 and younger. The fact that kids tend to have mild or asymptomatic disease — coupled with a parental aversion to subjecting small children to nasopharyngeal swabs — means they were probably less likely to be tested as well.
Still, hundreds of children and teens have tested positive for COVID in Toronto. The first confirmed case in someone 19 and younger was reported March 11, as families geared up for March Break. The girl in the Dovercourt-Wallace EmersonJunction
neighbourhood was infected through travel and recovered after hospitalization.
There have since been 963 more cases in kids or teens, mostly acquired through close contact with another confirmed case. And the neighbourhoods with the most infections in this age group are also in the northwest corner, where six communities have had more than 33 cases.
The area with the most infections, Downsview, has had 69. And the neighbourhoods with the most infections in kids are also in the northwest corner, where six neighbourhoods have had more than 30 cases each.
Fourteen kids have been hospitalized in Toronto, three in the ICU and one who was intubated.
One pediatric death has been recorded, a child under 10 from the Annex whose infection was acquired in an institutional setting. TPH said at the time that COVID may not have been the cause but Ontario’s chief coroner is investigating.
What will happen next with kids is the subject of intense discussion. Epidemiologists and pediatricians have different — sometimes wildly different — ideas about how school reopenings will affect Toronto’s epidemic, which is in remission.
Dubey noted that COVID’s twists and turns have been profoundly impacted by public health measures. The shape and scale of a potential second wave will largely hinge on what policymakers decide — and what happens to the 19-and-under case curve.
“The patterns that we saw in the first wave, certainly we’re reflecting on them,” she said. “But again, we’ve seen COVID and its transmission in our city change, even just from February until now. And so we can’t quite predict the future.”
The province only started allowing anyone who wanted a test to get one in late May after completing a push to test every LTC worker and resident
Graphics by Cameron Tulk, Nathan Pilla and Andres Plana