When should restrictions be lifted?
Experts say key data can offer insight into the risk associated with reopening during pandemic
As countries in Europe and other provinces in Canada begin lifting COVID-19 restrictions, some Ontarians may be wondering why they still have to live with them.
Unlike in Alberta, Saskatchewan, Manitoba and some U.S. states and European countries, there are no immediate plans to do away with mask mandates in Ontario. However, the province is looking to remove its vaccine passport system, Premier Doug Ford said in a press conference Friday.
This is because Ontario’s COVID situation looks bright, according to Dr. Peter Jüni, scientific director of Ontario’s COVID-19 science table. Though it’s hard to gauge the true presence of COVID in the province, as the speed with which Omicron spread became too much for our testing infrastructure, techniques like wastewater surveillance seem to show Ontario is on the other side of Omicron’s peak.
“Right now, we’re actually in a really positive spot in Ontario,” said Jüni, who said the next week or so will be crucial. “We’ve had a sustained decrease in case counts, based on what we’ve seen in wastewater. This is associated with a decrease in hospital and ICU occupancy, and it can be expected to continue until roughly Feb. 20.”
In Ontario, social gatherings are capped at 10 people indoors and 25 outdoors. Most indoor public spaces, including restaurants and movie theatres, are limited to 50 per cent capacity and require proof of vaccination at the door and that masks be worn by patrons unless seated.
If the virus continues to abate and people continue to get vaccinated, capacity limits will ease over the next month.
At the conference Friday, Ford stressed Ontario’s plan to remove restrictions is unrelated to the ongoing protests in the capital.
“We put this plan together well before this protest started,” said Ford. “I will never, ever negotiate (with) people that break the law.”
On Wednesday, Health Minister Christine Elliott said that while COVID trends are moving in a good direction, “we can’t sit back on our laurels and assume that it’s going to always continue.” She said the new Omicron sub-variant, which “certainly appears to be more transmissible,” has been detected in some parts of Ontario and is a reason to be careful.
Choosing when to lift restrictions and mandates is complex, factoring in many metrics and subject to the varying tolerances of governments around the world for the spread of sickness and death among their people.
But across Europe, countries, particularly Nordic nations, have begun easing COVID restrictions. Last week, Denmark became the first to lift all restrictions.
Experts say Denmark benefits from its high vaccine uptake, which grants it a more virus-resistant population that should burden the health-care system less. The country is now considering “winding down” its vaccination program in the spring, citing “large population immunity.”
But other countries with lower vaccination levels and higher death rates than Denmark, such as Sweden and the United Kingdom, are also easing restrictions.
So, when should Ontario lift restrictions? What benchmarks would it need to reach to make that decision reasonable? And what happens when countries open up too fast? The Star pulled COVID death, hospitalization and vaccination data and spoke with local health experts to help forecast the light at the end of the tunnel.
The factors that matter most when it comes to deciding to lift restrictions are test positivity, vaccine uptake, hospitalizations and hospital capacity, experts say. These are intertwined. A high vaccination rate means fewer severe cases, which means less stress on the health-care system. If two countries have similar hospital capacity, the more vaccinated country should fare better once restrictions are lifted.
Denmark and Ontario are comparable on two fronts: median population age, a good predictor of how disease-resistant a population should be; and percentage of the population that’s double-vaccinated — 80.9 per cent and 79.3 per cent respectively.
But two doses of the vaccine are no longer sufficient to prevent infection in the face of Omicron. It takes a third dose to provide notable infection prevention, and in that area the Danish soar above Ontarians, with 60.9 per cent having received boosters, compared to 45 per cent in Ontario.
Jüni said boosters offer a fivefold decrease in risk of hospitalization or death in those infected with COVID as compared with two doses.
“In addition, third doses will further slow the spread of Omicron in the short term,” Jüni said. “The most important thing is to have as many people as possible, especially (over 40 years old), receive third doses, so that we don’t have those people ending up in our hospitals, because they’re more vulnerable.”
Moreover, Denmark has more hospital beds per 1,000 residents than Ontario, which has fewer hospital beds per capita than any other province and some of the “most overcrowded hospitals in the developed world,” according to the Ontario Health Coalition.
As a result of its vaccine uptake and greater hospital capacity, Denmark has seen fewer total COVID deaths than Ontario — although deaths in Denmark in the past seven days have far outpaced those here. Hospitalizations there have also been rising since October, although ICU occupancy has declined in the last month. COVID cases in Denmark were more or less the same Thursday as they were two weeks before. On Friday, Denmark reported a slight drop in new weekly cases.
“I don’t think what’s happening in Europe is surprising at all,” said Dr. Saverio Stranges, chair of the epidemiology and biostatistics department at Western University. “In Europe, they are gradually lifting public health measures because many countries are seeing a declining trend in new cases. Vaccination is really mitigating the impact of hospitalizations.”
That trend is also observable in Ontario, which saw a decrease in both COVID cases and deaths this week.
Unfortunately, Jüni said, there has also been a decrease in booster shots administered. If more doses aren’t administered, Ontario could see hospitalizations rebound, he added. As of Tuesday, Jüni estimates Ontario is seeing roughly 30,000 COVID infections per day — only about 10 per cent of COVID infections are being caught, he said.
“We need to wait now, just another 10 days or so, just to understand where this is going, and not rush it, to not open blindly,” said Jüni.
Hospitalizations shooting up is always a concern in Ontario, where ICU capacity is perpetually pushed to the brink. High ICU occupancy is dangerous not just for people seriously ill with COVID, but anyone who might need critical care. Although the province has added more ICU beds throughout the pandemic, not all are equipped with ventilators necessary for COVID patients and not all hospitals have the staff to attend to all their ICU beds.
“The hospital capacity, in terms of ICU beds, we have in Canada is still not optimal, as compared with other western countries,” said Stranges. “Even in the pre-pandemic era, we worked at 90 per cent capacity, or above it.”
Yet, one country with even worse hospital capacity and worse vaccine uptake than Ontario is loosening restrictions. Sweden, which has historically taken a lighter approach to COVID mandates than most countries, ends most restrictions Wednesday.
This is perhaps why, despite having 4.5 million fewer people than Ontario, Sweden has had twice as many COVID cases and about 5,000 more deaths.
“Sweden pursued the idea of herd immunity; it tried to really be soft with restrictions, and that’s why it experienced much higher mortality per capita as compared to neighbouring countries,” said Stranges.
COVID restrictions save lives. For many, they also degrade quality of life and bring economic hardship.
This is the tug of war taking place among lawmakers around the world. Governments, Stranges said, make their values clear through their COVID restriction approaches.
“In the U.K. and U.S., I think it’s very clear they prioritized the economy from the very early stages of the pandemic,” said Stranges. “In Canada, we had a more balanced approach.”
The U.K. has also lifted restrictions, including mask mandates in public places. Although it has better vaccination than Ontario — though less than Denmark — it’s seen significantly more death throughout the pandemic, including in the past week.
And on Friday, the U.S. reached 900,000 deaths, by far the most of any country in the world. The U.S. has a total death rate per million of 2,736, and death rate per million in the last seven days of 44.8 — both among the highest in the world, followed closely by the U.K.
Just as the removal of stringent restrictions needs to be done carefully, so too does their implementation, Stranges said.
“We still have the tendency to just consider the importance of stringent measures without considering the side effects,” he said. “I don’t think we’re in a stage where lockdowns are sustainable anymore. School closures are not sustainable anymore — there is overwhelming evidence on the negative impact it has on our kids, especially elementary schoolers.”
Germany, which has one of the oldest populations in the world, and where infection numbers repeatedly hit new milestones last month, is planning to ease restrictions in some states, although federal Health Minister Karl Lauterbach said Monday that relaxing measures too quickly would be akin to “pouring oil on the fire.”
Lauterbach cited Germany’s vaccination rate as cause for concern in terms of loosening restrictions. With 54 per cent of its population boosted, it falls short of Denmark but is above Ontario. Germany also has one of the highest hospital capacities in the world — almost quadruple the hospital beds Ontario has per million people.
We need to wait now, just another 10 days or so, just to understand where this is going, and not rush it, to not open blindly.
DR. PETER JÜNI COVID-19 SCIENCE TABLE