COVID19: Let’s Talk About Ontario’s Re-Opening Plans

by Raywat Deonandan, PhD
Epidemiologist & Associate Professor
University of Ottawa
(I add my credentials to these COVID-19 blog posts in case they get shared. I want readers to know that my opinion is supposedly an educated and informed one)

Later this morning (May 18, 2020) I will be on CBC’s “The Current” to talk about the epidemiology of re-opening Ontario’s economy. I’ll be on-air with Dr Justin Fendos of South Korea and Dr. Tobias Kurth of Germany. Since I’m already thinking about the topic, I thought I’d take the opportunity to put some of my perspectives in writing.

How Should an Economy Re-Open?

The United Nations has put forth a fairly basic list of criteria to which member nations should adhere. Here are five:

  1. Confirm that transmission of the virus has been controlled.
  2. Build capability to detect, test, isolate, and treate every case of COVID-19, as well as tracing every contact.
  3. Ensure that outbreak risks are minimized, especially in hospitals and LTCs (long term care centres).
  4. Put into place preventive measures in workplaces, schools and other essential places.
  5. Educate their communities to prepare them for the “new normal” of living in pandemic times


What is Ontario proposing?

Earlier, Ontario had presented their broad framework for reopening. It consists of three phases:

Phase 1: Protect and support
Financial resources will be deployed to keep Ontarians safe, both medically and economically.

Phase 2: Restart
Several sectors will be allowed to restart. The key sentence for me is, “Public health officials will carefully monitor each stage for two-to-four weeks, as they assess the evolution of the COVID‑19 outbreak to determine if it is necessary to change course to maintain public health.”

Phase 3: Recover
Attempt to create jobs and to restore long‑term prosperity, while adhering to the “new normal”.

When this framework, as loose at it is, was announced, I felt it was fairly responsible. No calendar was attached to it, which is the important thing. It meant that the schedule would be driven by the science. I particularly like that it states overtly that the rate of opening would be driven by continuing monitoring of the public health situation.

We’re about to start Stage 1 of Phase 2. It includes the opening of some outdoor industries and store fronts. Schools are not open, nor are sit-in restaurants. These steps begin on May 19, and require physical distancing to still be respected.


Quick Thoughts on the Ontario Plan

I’m not qualified to comment on the economic implications of this disease nor of the re-opening framework. What jumps out at me, though, is how the Ontario framework does not map well onto the UN recommendations. What I would like to see more information about is:

  1. What steps are being brought in to further protect LTCs?
  2. What steps are being taken to communicate risk perception to the public?
  3. What indicators are being used to monitor the impact of re-opening on the public health situation?
  4. What is the plan for testing and contact tracing…. because that is critical to preventing/mitigating a second wave.


In other words, the public health infrastructure, so critical to making any of this work, is largely absent from any of the documents I’ve seen.


What Indicators Do We Care About?

As we re-open, we have to monitor the situation closely. This means keeping an eye on key indicators of disease progress. But which ones?

Obviously, we must always be looking at the number of new cases. Remember: this disease is probably not going to vanish. Now that we’ve driven the case load down to a fairly low number (as of today, Ontario has 3400 active cases in a population of 14.5 million people), any sudden and sustained climb in new cases might be indicative of the start of the dreaded second wave.

Consider this graph of the Ottawa new cases, applied to the IDEA model:

Ottawa COVID cases mapped onto IDEA model (May 17 2020)


If you just looked at the third last data point, you’d think a second wave already started. But it’s important to monitor this trend over several days to get a real sense of what’s going on. Otherwise you’d miss the strong likelihood that we are in fact at the tail end of the first wave.

It’s important, as well, to monitor the situation very carefully in key sentinel sites, like LTCs and prisons and schools (if any open). Better upcoming models will include a “compartment” (a source of cases) specifically for such populations, allowing us to better sense which communities are driving the epidemic locally.

We want to look at testing rate, for sure. But also at “tests per death.” If the number of tests for each death is small, then it is likely we are only capturing the more severe cases and are missing the less severe cases.

As the death rate dwindles (thankfully), the test-positive ratio becomes more important. Sometimes it’s presented as the test-per-case ratio, which is just the inverse of the test-positive ratio. What we want to see is that we are expending a great many tests to find a single case, implying that cases are increasingly rare.

Dr. Maria Van Kerkhove of the WHO once said,  “We would certainly like to see countries testing at the level of 10 negative tests to one positive, as a general benchmark of a system that’s doing enough testing to pick up all cases.”

But that 10% is just a diagnostic to see if a country is doing sufficient testing. A threshold for knowing if society is till “safe” is still unknown. But my personal preference is 1-2%. If we get it that low, we can have some confidence that we are capturing most of the cases in the community.

Of course, keeping a running estimate of R0 (the basic reproduction number) is important, too.


How Are We Doing Compared to Other Countries

My radio bit tomorrow is with German and South Korean experts. So let’s compare numbers (Based on OurWorldInData.Org) between our three countries.

Total COVID-19 cases:

Germany – 174,355 (doubling time = 43 days)
South Korea – 11,050 (doubling time = 74 days)
Canada: – 75,843 (doubling time = 26 days)

Total COVID-19 deaths:

Germany – 7914
South Korea – 262
Ontario – 1881

Case-Fatality Ratio:

Germany – 4.5%
South Korea – 2.37%
Ontario – 8.3%

Tests performed:

Germany – 37 per thousand people
South Korea – 14 per thousand people
Canada – 33 per thousand people
Ontario – 36 per thousand people

Test-positive ratio:

Germany – 5.4%
South Korea – 1.5%
Canada – 5.9%
Ontario – 4.3%

Deaths per test:

Germany – 0.25%
South Korea – 0.04%
Ontario – 0.35%


Is Ontario Ready?

We want to be South Korea. But Ontario is more like Germany, according to the indicators that I feel are important in monitoring COVID-19’s ongoing presence in our communities, as listed above. But our doubling time for the production of new cases is still too high to instill a lot of confidence in me.

Whether I like it or not, Ontario is starting to open up this week. My personal desire is for us to heavily ramp up public health powers and resources to assist in this process, as per the UN’s guidelines. In my opinion, here’s what needs to happen:

1. We have to continue on our current testing trajectory of attempting 20K per day. And that has to include lesser symptomatic people, not just the ones triggering a number of checks on the online assessment tool.

2. We have to start doing random screening. This can take the form of mobile testing units, home mail-outs, or grabbing random people on the street. But spot-checking the community is an excellent way to engage in active disease surveillance.

3. We should get our hands on as many rapid on-site tests as we can. These can be deployed at the entrances of LTCs and hospitals, or large places of work with controlled entrances.

4. We will never have the resources to do proper contact-tracing across the entire province. We must use technologies, like tracking apps, to help us. I understand that this is a civil liberties issue. But I’m just a lowly epidemiologist; the lawyers and ethicists can better navigate those murky waters.

5. We have to invest in the science to study the epidemiology COVID-19 transmission in children. Until that is understood, re-opening schools will be fraught with risk and panic.

6. Physical distancing should be the norm in all public encounters. This is already happening. But with government support and the power of law, this can be a supremely powerful tool in staving off a second wave. We’re already seeing this is marked off line-up stations to get into grocery stores. But places of work must move desks, change bathroom schedules, stagger work shifts… whatever it takes to reduce public risk.

7. In circumstances where physical distancing is not possible (e.g., elevators) the wearing of masks should be mandatory.

8. The thresholds for enacting more restrictions or closing sectors must be made clear to the public. For example, if the test-positive ratio jumps to 5%, that could be a signal to close down many businesses temporarily. If the public is aware of the indicators, there will be more buy-in for the plan, and greater efforts to keep that indicator from moving. (Keeping in mind Goodhart’s Law.)


Is The Second Wave Inevitable?

In a sense, yes, the second wave is inevitable. What is not inevitable is that the second wave will be noticeable or that it needs to be felt locally.

This is not one epidemic, it’s many epidemics with a different profile in each community and region. The global scenario might be stark, but it need not be so in our immediate province if we take steps to address its local characteristics.

Epidemics wax and wane, especially as populations respond in an attempt to mitigate their impact. By staying indoors and physically distancing and all the other painful things we have done these past two months, we shortened the height of that first wave. It looks like it’s coming to and end here in Ontario sometime in the next 60 days or so.

But the disease is not gone. We have not extinguished it from our communities. Some people are still infected and likely don’t know. So there will inevitably be a handful of cases that keep popping up. We have driven our national doubling time to 26 days. (Remember when that seemed unlikely?) This means that we should start seeing fewer and fewer cases, and seeing that doubling time to extend longer and longer.

But we will still see cases… hopefully they will occur less and less frequently.

The challenge for our public health system is to prevent a case here-and-there from becoming a genuine outbreak; and to prevent an outbreak from becoming an epidemic. If we can do this with incredible efficiency, the dreaded second wave might just manifest as localized outbreaks.

In other words, we have it in our power to prevent that scenario. We have it in our power to keep our economies open. All it takes is a heavy heavy investment in public health infrastructure, a responsive leadership willing to make tough choices when the moments arise, and a responsible citizenry willing to do its part to physically distance, wear masks, submit to random testing, and agree to be tracked.

It is a very tall order, I know. And I’m glad I’m not the one charged with making these decisions!

Can we do it? I’m pleased to see that one of my former students, Dr Patrick Saunders-Hastings, was recently quoted as saying, “We are better able to conduct… ‘test, trace and isolate’  …than we were earlier on in this outbreak.” It’s a positive perspective that suggests that we have learned through this epidemic what to do and how to do it.

The world as a whole has not yet reached its peak in terms of the disease’s capacity to spread, which means that much more global suffering is still ahead of us. But that does not necessarily mean that that has to be the case for us locally.

The trick, put simply. is to identify and isolate new cases quickly, so that they cannot mature into the dreaded second wave.

Can we do that? I have to think that we can.