People wait in their cars at the Credit Valley Hospital COVID-19 drive-thru testing facility in Mississauga, Ont. on Sept. 18, 2020.CARLOS OSORIO/Reuters
When Ontario released its daily COVID-19 figures on Friday, the topline number landed like a punch to the gut. There were 401 new cases, the most reported in a single day since June 7.
Ontario’s seven-day average of new infections per day – a measure that smooths out daily blips and makes trends easier to see – had nearly doubled by Friday from two weeks earlier. Quebec, Alberta and British Columbia have been reporting case spikes, too.
Lost in all of the entirely justified worry about growing case counts was another number in Ontario’s Friday report. That number was zero. The province of 14 million reported no new COVID-19 deaths, the 12th day of zero deaths since the beginning of August, according to The Globe and Mail’s tracking of provincial coronavirus statistics.
When it comes to public attention, COVID-19 death and hospital admission statistics in Canada have often taken a back seat to case counts. There’s a good reason for that: Both are lagging indicators that show where the coronavirus has been, not where it is now or where it will spread next.
“By the time you’re measuring hospitalizations and deaths,” said University of Ottawa epidemiologist Raywat Deonandan, “you’ve probably already lost the game.”
That said, coronavirus hospital admissions and deaths can’t be ignored either. There are lessons to be drawn from why the percentage of people with confirmed cases of COVID-19 who go on to die of the disease – known as the case-fatality ratio (CFR) – has dropped substantially in Canada since the pandemic began, according to the Public Health Agency of Canada (PHAC.)
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Infectious-disease doctors, critical-care specialists and epidemiologists say there are several reasons why fewer Canadians are dying of COVID-19, and they have more to do with who is catching the virus and how doctors are treating it than with the disease itself.
“It doesn’t seem that there are any drastic mutations or changes that we’ve seen that would suggest that we’re seeing a shift in how this virus behaves,” said Jason Kindrachuk, a University of Manitoba virologist who holds a Canada Research Chair in the molecular pathogenesis of emerging and re-emerging viruses.
Instead, the shift has been in the demographics of Canada’s coronavirus epidemic. More young people, particularly those under 40, are testing positive. Younger individuals can experience lingering health effects from disease – even if they aren’t hospitalized – but aren’t as likely to die. Meanwhile, far fewer elderly people are catching the virus than they were in the spring, when SARS-CoV-2 tore its way through seniors' homes.
COVID-19 cases by age group in B.C.
March 15 to Sept. 16
19 and under
20 to 39
40 to 59
80 and up
60 to 79
1
2
3
60
40
20
0
Mar.
2020
May
June
July
Aug.
Sept.
1
June 24
B.C. enters phase 3 of its economic recovery plan, which allows movie theatres, religious services, spas and vacation accommodations to reopen in the province.
Aug. 21
The province introduces a complaints-driven ticketing strategy focused on private indoor parties.
Sept. 8
B.C. orders nightclubs and banquet halls to close while some alcohol and noise level restrictions are placed on restaurants and bars.
2
3
Note: Age data are unknown for 164 cases.
THE GLOBE AND MAIL, SOURCE:
B.C. CENTRE FOR DISEASE CONTROL
COVID-19 cases by age group in B.C.
March 15 to Sept. 16
19 and under
20 to 39
40 to 59
60 to 79
80 and up
1
2
3
60
40
20
0
Mar.
2020
Apr.
May
June
July
Aug.
Sept.
1
June 24
B.C. enters phase 3 of its economic recovery plan, which allows movie theatres, religious services, spas and vacation accommodations to reopen in the province.
Aug. 21
The province introduces a complaints-driven ticketing strategy focused on private indoor parties.
Sept. 8
B.C. orders nightclubs and banquet halls to close while some alcohol and noise level restrictions are placed on restaurants and bars.
2
3
Note: Age data are unknown for 164 cases.
THE GLOBE AND MAIL, SOURCE:
B.C. CENTRE FOR DISEASE CONTROL
COVID-19 cases by age group in B.C.
March 15 to Sept. 16
19 and under
20 to 39
40 to 59
60 to 79
80 and up
1
2
3
60
40
20
0
Mar.
2020
Apr.
May
June
July
Aug.
Sept.
1
June 24
B.C. enters phase 3 of its economic recovery plan, which allows movie theatres, religious services, spas and vacation accommodations to reopen in the province.
Aug. 21
The province introduces a complaints-driven ticketing strategy focused on private indoor parties.
Sept. 8
B.C. orders nightclubs and banquet halls to close while some alcohol and noise level restrictions are placed on restaurants and bars.
2
3
Note: Age data are unknown for 164 cases.
THE GLOBE AND MAIL, SOURCE: B.C. CENTRE FOR DISEASE CONTROL
COVID-19 cases by age group in Alberta
March 15 to Sept. 16
19 and under
20 to 39
40 to 59
60 to 79
80 and up
1
2
110
100
90
80
70
60
50
40
30
20
10
0
Mar.
2020
May
June
July
Aug.
Sept.
1
June 12
Alberta enters stage 2 of its economic recovery plan, allowing most businesses and services to reopen, including theatres, gyms, casinos and personal care services. Indoor gatherings are capped at 50 people and outdoor at 100 with no size restrictions on religious services, restaurants and bars.
Sept. 9
Premier Jason Kenney says Alberta is not planning any business restrictions after the province had an average of 147 new cases per day in the week prior.
2
Note: Age data are unknown for two cases.
THE GLOBE AND MAIL, SOURCE:
ALBERTA GOVERNMENT
COVID-19 cases by age group in Alberta
March 15 to Sept. 16
19 and under
20 to 39
40 to 59
60 to 79
80 and up
1
2
110
100
90
80
70
60
50
40
30
20
10
0
Mar.
2020
Apr.
May
June
July
Aug.
Sept.
1
June 12
Alberta enters stage 2 of its economic recovery plan, allowing most businesses and services to reopen, including theatres, gyms, casinos and personal care services. Indoor gatherings are capped at 50 people and outdoor at 100 with no size restrictions on religious services, restaurants and bars.
Sept. 9
Premier Jason Kenney says Alberta is not planning any business restrictions after the province had an average of 147 new cases per day in the week prior.
2
Note: Age data are unknown for two cases.
THE GLOBE AND MAIL, SOURCE: ALBERTA GOVERNMENT
COVID-19 cases by age group in Alberta
March 15 to Sept. 16
19 and under
20 to 39
40 to 59
60 to 79
80 and up
1
2
110
100
90
80
70
60
50
40
30
20
10
0
Mar.
2020
Apr.
May
June
July
Aug.
Sept.
June 12
Alberta enters stage 2 of its economic recovery plan, allowing most businesses and services to reopen, including theatres, gyms, casinos and personal care services. Indoor gatherings are capped at 50 people and outdoor at 100 with no size restrictions on religious services, restaurants and bars.
Sept. 9
Premier Jason Kenney says Alberta is not planning any business restrictions after the province had an average of 147 new cases per day in the week prior.
1
2
Note: Age data are unknown for two cases.
THE GLOBE AND MAIL, SOURCE: ALBERTA GOVERNMENT
COVID-19 cases by age group in Ontario
March 15 to Sept. 16
19 and under
20 to 39
40 to 59
60 to 79
80 and up
1
2
3
220
200
180
160
140
120
100
80
60
40
20
0
Mar.
2020
May
June
July
Aug.
Sept.
1
July 24
The majority of Ontario’s public health units that make up the Greater Toronto Area, Hamilton and Niagara enter stage 3 of the province’s economic recovery plan, joining 24 units that advanced the week prior. Stage 3 allowed indoor dining and bars, gyms and playgrounds to reopen while limits on gatherings increased to 100 people outside and 50 inside.
July 31
Toronto and Peel Region enter stage 3.
Sept. 8
Ontario announces a pause on any further reopening plans for four weeks amid rising case numbers.
2
3
Note: Age data are unknown for seven cases. Ontario imposed new restrictions on social gatherings on Sept. 17.
THE GLOBE AND MAIL, SOURCE:
ONTARIO GOVERNMENT
COVID-19 cases by age group in Ontario
March 15 to Sept. 16
19 and under
20 to 39
40 to 59
60 to 79
80 and up
1
2
3
220
200
180
160
140
120
100
80
60
40
20
0
Mar.
2020
May
June
July
Aug.
Sept.
1
July 24
The majority of Ontario’s public health units that make up the Greater Toronto Area, Hamilton and Niagara enter stage 3 of the province’s economic recovery plan, joining 24 units that advanced the week prior. Stage 3 allowed indoor dining and bars, gyms and playgrounds to reopen while limits on gatherings increased to 100 people outside and 50 inside.
July 31
Toronto and Peel Region enter stage 3.
Sept. 8
Ontario announces a pause on any further reopening plans for four weeks amid rising case numbers.
2
3
Note: Age data are unknown for seven cases. Ontario imposed new restrictions on social gatherings on Sept. 17.
THE GLOBE AND MAIL, SOURCE: ONTARIO GOVERNMENT
COVID-19 cases by age group in Ontario
March 15 to Sept. 16
19 and under
20 to 39
40 to 59
60 to 79
80 and up
1
2
3
220
200
180
160
140
120
100
80
60
40
20
0
Mar.
2020
Apr.
May
June
July
Aug.
Sept.
1
July 24
The majority of Ontario’s public health units that make up the Greater Toronto Area, Hamilton and Niagara enter stage 3 of the province’s economic recovery plan, joining 24 units that advanced the week prior. Stage 3 allowed indoor dining and bars, gyms and playgrounds to reopen while limits on gatherings increased to 100 people outside and 50 inside.
July 31
Toronto and Peel Region enter stage 3.
Sept. 8
Ontario announces a pause on any further reopening plans for four weeks amid rising case numbers.
2
3
Note: Age data are unknown for seven cases. Ontario imposed new restrictions
on social gatherings on Sept. 17.
THE GLOBE AND MAIL, SOURCE: ONTARIO GOVERNMENT
In April, the overall COVID-19 CFR was 11.7 per cent, according to preliminary PHAC data crunched at the request of The Globe and Mail. By June, CFR was down to 2.5 per cent and in July it was 1.2 per cent. (PHAC’s August figures do not include Quebec. The province paused the sharing of detailed case reports with PHAC while replacing its IT platform, a spokeswoman for Quebec’s health ministry said.)
Overall case-fatality ratios should always be taken with healthy skepticism. The denominator depends on testing, and Canada reserved most of its tests for the severely ill in March and April, making the disease look deadlier than it was.
But case fatality ratios for COVID-19 patients admitted to hospitals and intensive-care units have also fallen, according to PHAC figures up to Sept. 9. In April, 27.5 per cent of hospitalized patients (excluding ICU patients) died. By June it was down to 16.3 per cent and by July it was 11 per cent. The drop wasn’t as sharp in the ICU, where case-fatality ratios fell from 31.8 per cent in April to 29.7 per cent in June and 22.6 per cent in July.
Caroline Colijn, a professor at Simon Fraser University and Canada 150 Research Chair in mathematics for evolution, infection and public health, said the sea change in who is testing positive for the coronavirus is the most straightforward explanation for why so few Canadians, relatively speaking, have died of COVID-19 recently.
The lag between catching the virus and dying also plays a part, she said. Today’s low death counts reflect last month’s success in suppressing the virus. Canada’s seven-day average of newly reported daily deaths fell to three on Sept. 10, the lowest since the pandemic took off. At the peak in early May, that figure was an average of 176 deaths a day.
Like many epidemiologists, Dr. Colijn is convinced that as case counts climb, the young will pass the virus on to the old, putting them at risk. “No age group is an island,” she said.
Samir Sinha, the director of geriatrics at Sinai Health System and the University Health Network in Toronto, said Canada’s success in driving down deaths over the summer was tightly linked to keeping the virus mostly out of seniors' homes. That is much is easier to do when there isn’t much virus circulating in the community, he added.
“Are we better positioned than we were six months ago? Absolutely," Dr. Sinha said of seniors' homes, whose residents account for about three-quarters of the Canadians killed by COVID-19. “We’re all getting a bit tired of physically distancing. We may not be as vigilant in donning and doffing our PPE because, frankly, things have been okay for a while. This is where we get lax and COVID invades."
There has been an uptick in cases in long-term care facilities since Sept. 1. But when seriously ill COVID-19 patients land in hospital, they’ll find physicians better able to save their lives, armed as they are now with experience treating the disease and with steroids that have been shown to cut the risk of death by a third in the sickest patients.
Amol Verma, a general internist at St. Michael’s Hospital in Toronto, is one of the leaders of the COVID-19 Hospital Analytics Laboratory, a research project harnessing data from Ontario hospitals to figure out how to better care for COVID patients.
He said that German data looking at case fatality ratios stratified by age pointed to improved care saving the lives of the infected.
“Does an 80 year old who gets affected with COVID-19 today have a better chance of surviving? The answer there is yes," Dr. Verma said. "And I think it’s very reasonable to assume that it’s a combination of the treatments that are available, including early recognition [of infection] and good supportive care.”
Delivering that top-quality care hinges on hospital capacity. The fear remains that a gargantuan second wave could overwhelm hospitals in a way the first wave didn’t.
In the second week of May, the number of Canadians in hospital with COVID-19 peaked at just over 3,000.
On Thursday, that number was 302.
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Kelly Grant