Ontario has drawn its COVID-19 red line. What now?

OPINION: The province’s new modelling tells us under what circumstances the health-care system can operate as usual. This is useful to know — but it tells us less than you might think
By Matt Gurney - Published on Sep 30, 2020
David Williams, Ontario’s chief medical officer of health, makes an announcement at Queen's Park on August 13. (Christopher Katsarov/CP)

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We now know where Ontario's red line is. The challenge will be knowing when we’re close to crossing it.

In a briefing on Wednesday, some of the province's top public-health and medical officials unveiled new modelling for the second wave of the pandemic. As expected, there is a low scenario, a high scenario, and a medium scenario — and Ontario is, right now, tracking closely with the low version (slightly below it, in fact). That was the good news. There was bad news, too. Cases are going to climb dramatically in the next few weeks, Ontarians were warned. And, ominously, we are starting to see COVID-19 infections migrate from younger, more robust individuals to older, more vulnerable ones.

This has, for weeks, been the key indicator to watch. COVID-19 remains sneaky and mysterious in many ways, but what is manifestly clear is that it is lopsidedly lethal to older individuals. A slide released as part of Wednesday's briefing tells the tale. More than 4,000 Ontarians aged 19 and younger have had confirmed COVID-19 diagnoses; one has died. This is a CFR — case-fatality ratio — of effectively zero. But the CFR is 9 per cent for those between 60 and 80 and a ghastly 30 per cent for those over 80. In recent weeks, many have dismissed the rising case counts in Ontario as a "casedemic," noting, correctly, that since the infections were among the young, the health outcomes would likely prove minor. But there is no magical forcefield separating Ontarians neatly into decadal cohorts. We know what this means.

We now know something else: Ontario has revealed something that seems to be functioning as a public-health red line of sorts — a line that, if crossed or even approached (more on that distinction in a moment!), may trigger more stringent restrictions in at least some regions of the province.

I wrote about the need for such a red line two weeks ago here at TVO.org. "Hospital capacity could be our metric" for what constitutes a red line, I wrote then. "[M]etrics could be weighted to local conditions and then adjusted: for example, in the event of a major second wave, hospital capacity would likely bounce up and down as health-care workers fell but also as new field facilities opened. As capacity shifted, so could the red line."

And this seems, more or less, to be the agreed-upon metric. At the press briefing on Wednesday, the officials said that they are closely watching hospitalizations and that the health-care system's ICU-bed inventory will be critical. So long as the number of ICU beds required for COVID-19 patients remains below 150, the government has concluded, the health-care system can maintain normal operations. Abnormal operations, actually, in a way: Ontario is trying to clear up a backlog of procedures created by the first wave, and it can continue to do so provided that COVID-19 patients take up fewer than 150 beds. The flipside: if COVID-19 patients take up more than 350 beds, the province has concluded, maintaining relatively normal health-care operations will become impossible.

This is useful to know. Right now, we are not anywhere near even the lower figure: at time of writing, there are about 30 COVID-19 patients in ICU beds. That leaves us with a margin of 320 — nearly 11 times more than we have right now. That is, on the face of it, encouraging. We have capacity in the system. We can absorb heavy, painful losses — each of them tragic — without threatening the integrity of the health-care system itself.

But I noted above the distinction between crossing or even approaching a red line. Infections and illnesses are both lagging indicators. People become infected before they become ill, and they become critically ill gradually. Knowing that the health-care system's red line is 350 COVID-19 patients in ICU is helpful, but what will still be a matter of judgment is at what point to bring out a more draconian round of restrictions to prevent us from hitting 350. If our cases climb slowly and steadily, we could get lucky; we may have enough time to see any danger coming and gradually reimpose targeted, evidence-based restrictions to keep us below that 350-bed threshold.

But that’s the best-case scenario. The case counts might soar rapidly; our testing capacity might be exceeded, robbing us of the essential early-warning system all our responses depend on. We might also just get plain unlucky. A few outbreaks in institutional settings — a large school, a long-term-care facility, an industrial workplace — could take a slow, gradual rise in cases and blow up the number dramatically. That would likely result in a rapid and less targeted round of restrictions that might ultimately prove to be too little, too late.

Either of these scenarios is possible. There are no guarantees. Premier Doug Ford and his officials might have to make decisions to avoid tipping over 350 while the number of patients in ICU is what? Half of that? Two-thirds? Fewer? More?

I don't know. It's unlikely anyone does. But we do at least now have a metric to watch. It's not much comfort, but it's something.

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