HAMILTON — In March, Hamilton Public Health Services became aware of a number of COVID-19 cases at Rebecca Towers, a 17-storey, 164-unit building in the Beasley neighbourhood. Staff then began repeatedly noticing that same address coming up — and on May 4, public health declared an outbreak.
“It's important to realize that, of course, there will be some cases that occur in such a large building at any time,” Hamilton’s medical officer of health, Elizabeth Richardson, said at a May 10 media briefing. “It's when they build up to such a level that you start to be concerned [there may be] some other reason for transmission occurring. And then we would go and investigate.”
When the outbreak was declared, officials said that residents in 17 units across 10 floors at 235 Rebecca Street had been infected with COVID-19. As of May 17, there were 110 cases, and one person had died. It’s one of the city’s largest outbreaks and was the first to be identified in a multi-unit residential building in Hamilton.
Since May 4, two new outbreaks have been declared at apartment buildings in the city. At the Village Apartments on 151 Queen Street North, 69 cases were confirmed as of May 17. As of that same day, public health had logged 42 cases in residents at the Wellington Place Apartments at 125 Wellington Street. These cases — and apartment-building outbreaks in Peel, London, and North Bay — are raising questions and concerns about how the coronavirus spreads in multi-unit residential buildings and what tenants, property managers, and public-health officials can do to keep them safe.
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Public-health officials attribute the Rebecca Towers outbreak to close contact between people from different households, and Richardson has said that the building was well-maintained. A spokesperson told TVO.org via email that the department confirmed this “through case management of confirmed cases and infection prevention and control inspections.”
Rebecca Towers residents have told reporters they don’t understand how that explanation could account for so many cases and pointed instead to other factors — such as the fact that the building has had just one working elevator for months. While public-health officials say they hadn’t seen evidence of transmission in the elevator, current and former tenants say crowding in the elevator was common.
Hyeisha Campbell, an organizer with the Rebecca Towers tenant committee, says she and her young daughter moved out of the building in April and were not aware of the COVID-19 outbreak until public-health officials announced it in May. “It’s just really concerning. I'm happy, and I feel blessed [to be out]. But, at the same time, there are good people that have been staying at home caring for their families the best that they could through all of this.” Campbell says that, even with a two-person limit on the elevator (which is what Hamilton public health recommends in its guide for people living in and managing multi-unit dwellings), it was “100 per cent” unsafe for so many people to rely on using such a tiny space.
While Richardson says it’s not in public health’s purview to tell the building’s landlord, the Medallion Corporation, to quickly fix its elevator, she says that doing so has come up in conversations with the company as something that would allow for better physical distancing.
Tenants have also raised concerns about ventilation. Emily Power, an organizer with the tenant committee who lives in the same neighbourhood as the tower, says some tenants believe the systems in the building are inadequate, resulting in poor airflow. “I would say that the majority of tenants in the building take the COVID-19 precautions very seriously and wear masks and distance,” Power says. “There are some people in the building who haven't been as careful. And I think this has been a wakeup call for those people.”
For its part, Medallion has told reporters it continues to support public health in controlling the outbreak and is working to address essential repairs, including the elevator, and to ensure that all systems in the building are functioning well. (TVO.org reached out to the Medallion for comment but did not receive a response by publication time.)
A Hamilton public-health spokesperson tells TVO.org that “transient exposures to others outside one’s household can occur in elevators and hallways” but adds that no specific cases of COVID-19 transmission linked to airflow in residential buildings have been identified in Hamilton. That said, they note, it’s important to maintain good airflow and ventilation to help prevent transmission: “Review of these issues continues to be considered as part of outbreak investigations.”
At a May 17 Hamilton Board of Health meeting, councillors and Hamilton mayor Fred Eisenberger repeatedly asked Richardson to explain how public health determined that airflow had not been a primary factor in the outbreak. She said that, as part of the investigation, HPS had talked to Public Health Ontario and PHUs in London, Peel, and North Bay about their experiences with apartment outbreaks and that it is difficult to test for and verify the role of airflow in transmission. But, she said, “There are outbreaks where it has been identified as being a source.”
While noting that local public-health units likely have access to more information than Public Health Ontario does, JinHee Kim, a PHO physician who specializes in environmental health, tells TVO.org via email that her organization is also unaware of any Ontario cases in which poor ventilation or elevators have been contributing factors to transmission.
In a March 2021 paper, Public Health Ontario identified well-functioning heating, cooling, and ventilation systems (HVAC) as helpful in preventing COVID-19 transmission, as they remove and dilute aerosols that may contain viruses from indoor spaces. It states that there are “many studies on ventilation related factors that demonstrate the risk from inadequately ventilated indoor spaces, as well as studies that have documented transmission under circumstances of likely inadequate ventilation.”
Kim says that, overall, there are predictable risk factors for multi-unit residential buildings: “In situations where large numbers of people are living in the same building, in close proximity to each other and sharing amenities, it is expected that there will be opportunities for transmission. So it is important for common spaces and surfaces to be managed appropriately, such as limiting crowding in areas like hallways, elevators, laundry rooms, and mail rooms; ensuring good maintenance of building ventilation and cleaning; and for residents to follow building policies on COVID-19 and general public health advice to prevent transmission.”
Isaac Bogoch — an infectious-diseases physician and member of Ontario’s vaccine task force — says that apartment-building outbreaks require detailed investigations but points to two important considerations: air and human behaviour. “There are probably several, or multiple, factors that are playing into this, and one of them is the potential for airborne spread of this virus in certain settings. I think you just cannot ignore that,” he says.
Bogoch adds that situations in which people are in close proximity — such as when they’re in elevators or in others’ units — allow for the possibility of more transmission. “I'll tell you what's not causing this,” he adds. “Touching. It's not from fomites [objects or materials likely to carry infection]. It's not from elevator buttons or doorknobs — that's not going to be driving an outbreak. We know that at this point in time.”
While Hamilton is in the early stages of studying its apartment-building outbreaks, the North Bay Parry Sound Health Unit already has a list of takeaways from managing one at a local apartment complex in February and March during which 45 people were infected and three died. (TVO.org asked the Ministry of Health if it was aware of how many COVID-19 outbreaks have been documented in multi-unit residential buildings in Ontario but did not receive a response by publication time.)
In an email to TVO.org, a spokesperson for the North Bay Parry Sound District Health Unit says it’s too early in the investigation to share results and adds that there is “a lack of research on COVID-19 outbreaks in multi-unit dwellings.” Still, they say, the health unit has learned “a great deal” about apartment outbreaks, including the importance of working with building management, communicating often with building residents, offering regular on-site testing, and “if possible, [utilizing] COVID-19 vaccination as an outbreak management strategy.”
Hamilton public health says it will vaccinate homebound residents of apartment buildings where there are outbreaks but not hold clinics in or immediately outside buildings. Instead, it’s working to get residents to mass-vaccination sites. Over the weekend, about 58 residents got shots at a mass-vaccination clinic, and 28 were offered jabs in their units, though, for various reasons, not all ended up receiving them.
David Elfstrom, an energy engineer who worked on the North Bay investigation, says he thinks unit-to-unit transmission of COVID-19 through the air may be happening under the radar of public-health officials. “We know that air is shared between units — and we know that airborne transmission of SARS-CoV-2 exists,” he says, noting a review of risks in multi-unit residential buildings by the National Collaborating Centre for Environmental Health.
Any building that experiences an outbreak should be investigated by an engineer to ensure that HVAC systems are working as intended and that air is properly moving in and out of units, he says: “A proper ventilation system has filtration and introduces outdoor air. So those two factors, right there, greatly reduce risk.”
He suggests that tenants check their units for air gaps around plumbing, ensure air is coming under the door to the hallway, and confirm that exhaust fans in the bathroom and kitchen are sucking air out of the unit. He also recommends that residents open windows as often as possible to, as the NCCEH says, “increase air exchange and reduce the presence of respiratory particles.” Elfstrom adds that using an air purifier can also help by capturing airborne contaminants, such as viruses, in one’s unit.
At the May 17 board of health meeting, Richardson told council that Hamilton public health has advised Medallion to review ventilation and airflow in Rebecca Towers and report back with its findings.
Hamilton public-health director Michelle Baird said at the meeting that, in two-thirds of cases, spread in apartment buildings was happening within the household. She added that public-health staff has identified ties between apartment outbreaks and other workplace outbreaks — notably, ones in warehouses, where many residents in the affected buildings are essential workers. Overall, she said, there seems to be a higher rate of COVID-19 infections in the neighbourhoods where the buildings are located, likely due to socio-economic factors, such as employment and housing precarity.
Tina Novak, the president of the Hamilton and District Apartment Association, which represents property managers and rental-housing providers, says it’s been challenging for property managers to keep buildings safe during the pandemic, because they can’t easily enforce rules such as capacity limits on elevators or masking in common areas.
Novak adds she feels for everyone involved. “Maybe this will be enough to help the rest of the building communities realize this can happen in their homes, too. So be safe … and do all those things that are necessary to keep everybody safe,” she says. “I don't like some of pointing of the fingers. I think that tenants, management staff — we all just need to solve this and work together. That's the bottom line.”
With files from Nathaniel Basen.
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