Thunder Bay District's first COVID-19 case was reported about one month ago - on March 26th. Since then, the number of cases have grown but the number of daily new cases appears to have declined from the peak reached April 15th. We have however, also registered out first death as of April 23rd and given mortality rates from the illness, one can probably expect a couple more deaths based on current case load numbers. The first figure below shows the steady ascent from the first case to the current (as of yesterday) total of 63.
The ascent appears to have slowed since the 21st and the next figure plotting daily new cases does appear to show a distinct hump peaking somewhere between April 11th and April 15th. If over the next week, growth in new cases drys up completely then it may be that the pandemic has failed to take firm root in our part of Ontario. This is certainly good news, but not a cause to relax given the need to maintain physical distancing protocols and precautions in the absence of either a cure or a vaccine.
Its not over yet. Maintaining personal discipline over the next few months is crucial to arresting the progress of this virus.
Acting on the advice of the Chief Medical Officer of Health and
other health care professionals, the Ontario government has significantly
expanded hospital capacity in preparation for any COVID-19 outbreak
scenario. The province has added 1,035 acute care beds and 1,492 critical care
beds and taken steps to ensure hospitals have the staff available to care for a
sudden surge in patients. Based on Ontario’s population and 2017-18 total
hospital bed numbers from the CIHI, this should boost the total number of
hospital beds per capita in Ontario to 2.5 per 1,000 population. Moreover, there are plans to add further
capacity in terms of bed numbers.
Expansion of capacity and associated funding to staff those beds is
necessary to deal with the COVID-19 outbreak but it is also necessary to deal
with future health demand because hospitals in Ontario have seen their per
capita hospital bed numbers and real per capita hospital spending stay flat for years. Real per capita
provincial government health spending in Ontario from 2000 to 2019 grew 39
percent but growth varied across the health expenditure categories.Hospitals in Ontario over this period
only grew by 14 percent with much of it before 2010 and since 2012 has been
essentially flat.The largest
increases were in per capita public health (133 percent), other health spending
including home and community based care (101 percent) and drugs (59 percent).
Across Canada’s ten provinces, Ontario currently has the second
lowest number of total hospital beds per 1000 people after Quebec at 2.3 beds
per thousand (which will grow to 2.5 with this announcement) with Quebec coming
in at 1.9.Newfoundland comes in
the highest at 4.6 beds per thousand followed by New Brunswick at 3.8 and
Manitoba, Prince Edward Island and Nova Scotia all tied at 3.4.Ontario, like many Canadian provinces
has developed a “just in time” hospital care system with little spare capacity.In the past, winter months often saw
surges resulting in hallway medicine because of surges in demand from seasonal
flu.
Currently the reports are that hospitals in Ontario have been
coping well as the anticipated peak surge due to COVID-19 appears to have been
held back by the implementation of public health protocols such as physical
distancing and shutdowns of activity.Assuming
the additional beds and staffing can be put in place quickly, it better
positions Ontario hospitals for any surge in COVID-19 and boosts capacity for
the period afterwards.That is
good news because to date the expansion in the current ability to free up beds
has been done by rationing access to services.Essentially, beds have been freed up
by sending as many patients as possible home, delaying elective surgeries and
postponing deemed non-urgent surgeries.As well, demand for emergency services is down as people delay going to
seek treatment which has ramifications for future need as people put off
seeking medical care.
Given that we may be nearing a
slowing down in the growth rate of total confirmed cases in Ontario
Covid-19 cases, I think the ability of the health care system to deal with
Covid-19 will be even more secure especially as more beds come on stream and
supplies of critical materials and PPEs increase.This will hopefully result in
hospitals starting to resume dealing with elective and non-urgent surgeries and
their usual diagnostic testing services given that almost all of this has been
put on hold.The postponing of
other health procedures is detrimental to the long-term health of many
Ontarians and is an additional cost of the Covid-19 pandemic in terms of both
its potential effects on general future mortality and morbidity as well as
future health care costs.
Running a “just in time” public health care system at capacity with most
activity – diagnostic, acute care, surgeries and emergency services - mainly
concentrated at large centralized hospitals will need to be revisited.We need a more resilient health care
sector that able to cope with surges in demand in crisis situations as well as
continue to provide other needed health services.One can hope that in future, along
with a reinvestment in hospital capacity and proper maintenance of public
health equipment stockpiles, one will see an expansion of broader function
“Urgent Care Centers” across the province that will provide a range of
emergency type services outside of hospital settings as well as more
decentralized diagnostic clinical centers that are able to do minor elective
procedures outside of a major hospital setting.The current approach to the health
care system in Ontario is essentially akin to putting all your eggs in a very
small and fragile basket.
It is now Day 85 of the start of the Covid-19 pandemic in Ontario as dated from the first case on January 25th of 2020. There are signs of the epidemic peaking in parts of Canada like British Columbia and Saskatchewan along with discussion of the gradual reopening of activity in measured and methodical ways. In Ontario, as of Saturday morning the 18th of April, there have been 10,010 confirmed cases of COVID-19 and a total of 514 deaths. The number of new cases reported today was 485, down from 564 the previous day and 514 the day before that. There has been some talk in Ontario also that the pandemic may be slowing and that there is some cause for cautious optimism. Indeed, the province is expected to release new modelling numbers on Monday that some have hinted may show some support for optimism.
Well, in anticipation of that, here is my go at the numbers to date using STATA and a simple data smoothing regression technique known as LOWESS. Figure 1 plots the total number of cases since Day 1(January 25th) when there was the first case to the present with the red line as the smoothed curve. Needless to say, this figure does not look particularly reassuring but it is the total cumulative number of confirmed cases and the more appropriate graph in order to judge growth rates in the total case figure is Figure 2 which presents the log of total confirmed cases. Here the evidence still shows an increase but somewhere around Day 70 - that is around April 3rd - there does seem to be a change in the growth rate and the curve trends upwards less steeply. This is a bit of good news.
Figure 3 is yet another go at the numbers, this time a plot of the number of new confirmed cases per day again with a regression smooth. The number of new cases per day begin to soar circa Day 50 which is March 14th but again note that the trend in new cases per day - as visualized by the LOWESS smooth - goes up at a lower rate again circa the April 3rd point.
However, the best news of all comes from looking at the growth of cases per day in terms of daily percentage growth rates in total confirmed cases. Figure 4 presents this data with the accompanying LOWESS smooth. One can discount the far left of the diagram as this is the start of the pandemic with few cases and therefore some very large growth rates when the number of cases double. The data smooth line basically shows the increase in growth rates picking up steam after Day 20 - which would be the 13th of February though the actual data starts picking that up closer to Day 30 which is February 23rd. The daily percent growth peaks a bit before Day 60 - March 24th - and then starts to slowly come down. Growth has been under 8 percent since April 11th and just fell below 6 percent in today's release coming in at 5.1 percent.
So, despite my limited knowledge (borrowing from Star Trek, "I'm an economist Jim, not an epidemiologist!"), I would hazard to guess that the infection numbers today reflect what was going on about ten days ago. This gets further complicated by the fact that we are running more tests today than we were ten days ago and indeed a month ago. Nevertheless, if we are testing more and the total number of new cases is stable but not soaring and the percentage growth rates seem to coming down, then yes we may be on the verge of bending the curve downwards and getting the pandemic under control in this province. Assuming over the last 10 days, we have all continued physical
distancing and taking precautions and the number of tests is maintained at current levels or increased, then the growth rates this week should
come in about 5 percent at the start of the week and then head down towards 4 percent by Friday. Let us hope.
The Covid-19 pandemic is now well underway in Ontario. Between March 1st and March 31st, the total number of confirmed cases rose from 15 to 1,966. From the first death on March 17th, the number of deaths grew to 33 by March 31st. Since March 31st, total confirmed cases have grown to reach 4,726 (as of April 7th noon-time) and the total number of deaths have climbed further to reach 153. What is quite interesting is plotting the numbers as the public health sites present case totals but plots to help assess trends are not readily in evidence.
Figure 1 plots the total confirmed cases in Ontario announced to today and they reveal a very steep curve of ascent. What is also interesting is looking at the change in cases per day which is plotted in Figure 2. The number of new cases was the highest on April 2nd at 573 and since then have essentially bounced up and down in a band from 290 to 408. If this latter trend is maintained and then starts to show decline, we may be indeed be at a turning point in the war against COVID-19 but it is still too early to tell.
What is also of interest is what the figures look like here in the Thunder Bay District. It is early days yet in the Thunder Bay District with the first case being reported March 27th. However, as of April 6th, Figure 3 shows what the total cases and the new cases per day looks like. There of course have yet to be any reported deaths in the Thunder Bay District
It is still what looks like a fairly leisurely ascent - somewhat similar to Ontario as a whole in early to mid-March but we are now in early April. The March breakers have been back for about two weeks and hundreds of our local snow birds have also been returning. If we have taken the self-isolation an distancing protocols to heart, then hopefully this will not rise too steeply and also begin to flatten out. We certainly have had plenty of notice and warning given what has happened around the world and in the rest of the country. The next week will be crucial in both Ontario and Thunder Bay District.
I'm not an epidemiologist by any stretch of the imagination but economists have data analysis skills that are relevant here. Here are some pretty stark charts of the current Covid-19 crisis in Ontario. Covid-19 in Ontario actually dates from a first confirmed case on January 25th with a first death on March 17th. The figure below plots confirmed cases and the daily change in cases and show a more rapidly escalating curve for total confirmed cases starting around March 11th. The change in the number of cases picks up quite dramatically after about March 27th - not that long ago. From one case on January 25th, Ontario has ramped up gradually with an acceleration over the last week and as of April 2nd, has 2,965 cases. At the time of posting, Ontario had added 573 cases today - the biggest daily increase yet.
If the rates of change are not arrested - that is, the orange line in the above figure first flattens and then declines - one is headed towards a catastrophe. Take the example of Italy. Believe it or not, on January 25th, Ontario had one confirmed Covid-19 case while Italy had zero. Italy acquires two cases on January 31st. From two cases on January31st, the Italian pandemic exploded and as of April 1, stands at 110,574 confirmed cases.
Italy is of course much larger than Ontario in terms of population with about 60 million people compared to Ontario's 14 million so a comparison of cases per million population is useful. As illustrated below, Ontario to date has had a more gradual spread. While Italy is currently at just over 1800 cases per million population, Ontario is at 205 cases. Despite almost identical starting points, Ontario appears to date to have been spared the more rapid increase that occurred in Italy with a key divergence point between the two countries being the first week of March. However, we are at a crucial point given that in Ontario as in Canada as a whole, the tepid rates of increase prior to mid-March lulled us into a false sense of security. Tens of thousands in Ontario and Canada embarked on their March breaks and have since returned. As well, snowbirds and other international travelers have come home. Travel is the key factor in the initial ignition of Covid-19 and its contribution in the post March break period can only be halted by rigid adherence to physical distancing.
If Ontario's infection rates per million and resulting total confirmed cases had behaved like those of Italy, at this point we would - based on Italy's case numbers per million - be at over 26,000 Covid-19 cases in Ontario and with a much larger death toll. As the figure below illustrates when comparing Ontario's actual Covid-19 numbers with a simulated amount using Italian infection spread rates in terms of cases per million, the difference is stark. At Italian rates of spread and infection, Ontario would have reached 400 total cases by March 4 and would now be at just over 26,000.
Such a counterfactual exercise is extremely revealing as to how bad this could have been to date - and how bad it could still get. We cannot afford to be complacent or not take this seriously. Ontario - and Canada - still have the ability to halt this pandemic in its tracks but it requires discipline and adherence to social and physical distancing rules on all our parts before it is too late.
