Medical Officer of Health Letter: Need for Enhanced Public Health Measures

Backgrounder
October 2, 2020

Dr. David Williams
Chief Medical Officer of Health, Public Health
Ministry of Health
393 University Avenue, 21st Floor
Toronto, ON M5G 2M2

Dear Dr. Williams:

Re: Need for Enhanced Public Health Measures

As you know, the number of COVID-19 cases in the City of Toronto continues to increase. Specifically, the 7 day moving average on Sept 1 was 40, on Sept 17 was 84, and on Sept 29 was 236 – an almost six-fold increase. Based on observations of case trends in other jurisdictions and several rapid changes in the COVID-19 case data, the City is at risk of experiencing exponential growth of COVID-19 infections in the immediate future.

I would like to commend you and your team for the ongoing collaborative efforts between the Province of Ontario and the City of Toronto throughout the COVID-19 pandemic. However, without quick action from the Province to implement further public health measures, there is a serious risk that the City will not be able to prevent the health and economic impact resulting from this surge, particularly with the imminent change in season. Based on the experiences of other jurisdictions, smaller scale policy changes will not be enough to stop virus transmission, and large-scale action is needed.

While testing has increased, on some days, the City has experienced higher daily case- counts than were experienced during the first wave of the pandemic (e.g. 381 cases on Sept 28 and 321 cases on Sept 29). As you know, the goal is to keep the reproductive number below 1.0. However, based on analysis by Toronto Public Health and the Province of Ontario, the reproductive number for Toronto is estimated to be between 1.2 and 1.4.

We have made the following critical observations:

  • Currently in Toronto, there are approximately 169 active outbreaks. These include those in the community, as well as those in congregate settings, schools, childcare centres, workplaces, and long-term care homes. In the last three weeks, we have seen long-term care outbreaks increase from 2 to 9.
  • Between September 20 and 26, there were 45 active community outbreaks. Of these outbreaks, about 18 (44%) were in restaurants, bars and entertainment venues.
  • Socializing in bars and restaurants is contributing to significant exposures and outbreaks (e.g. Yonge Street Warehouse created 1,700 exposures, Regulars Bar created 600 exposures).
  • We have observed accelerated growth in schools since reopening on September 15: 103 schools with active cases, 68 in the last week (Sept 23-Sept 30). To allow for safe reopening, such as opening schools, it is recommended that communities keep new case counts to no more than 1 case per 100,000 population/day. For Toronto, this would be approximately 30 cases/day. Currently, Toronto’s 7 day moving average for new cases is 8 cases per 100,000 population/day (CIDRAP, Osterholm Update: Reopening Schools July 2020).

Learnings from Other Jurisdictions

We have been monitoring trends and effective public health measures in other comparable jurisdictions. The State of Victoria, Australia, which includes the Melbourne metropolitan area with a population size that is comparable to Toronto, implemented strict public health measures when daily case counts were lower than those currently occurring in Toronto:

  • Stage 1 – When cases were at ~165 cases/day (2 cases per 100,000 population/day), individuals could only leave home for work, education, fitness and essential activities (Statement from the Premier). On October 1, Toronto had 280 cases.
  • Stage 2 – When cases were at 466 cases/day (9.51 cases per 100,000 population/day), a complete lockdown was implemented in the Melbourne metropolitan area, including a nightly curfew. Toronto is currently at 8.8 cases per 100,000 population/day, and experienced 381 cases on September 28, 2020.

After seven weeks of Stage 2, Victoria State had very few cases (7-day moving average of 28 cases/day, 0.6 cases per 100,000 population/day), as compared to jurisdictions where they implemented very few public health measures.

The situation in Toronto has transpired in spite of significant effort on the part of the Ministry of Health, the Province of Ontario and Toronto Public Health to enact legislation, bylaws, enforcement, case and contact management, as well as several strong recommendations to the public regarding how they can prevent virus spread. Therefore, I am writing you to indicate the need for further, immediate action.

Recommendations

As the Medical Officer of Health, it is my responsibility to identify health risks, such as the accelerated transmission of COVID-19; to identify actions to mitigate the risk; and, if I cannot take actions within my authority, as is the situation in this case, it is my duty to notify the appropriate parties of the risk to Toronto residents. Given the evidence I have reviewed, I am concerned if we do not act quickly to enhance public health measures, we will not adequately mitigate the immediate health risks to the public. To that end, I am recommending that you consider immediately implementing the following temporary public health measures in Toronto for a period of approximately one month:

  1. Restaurants and Bars: Having observed transmission in restaurants and bars, as well as to arrest community spread of COVID-19, I recommend restricting individuals from dining indoors. We have explored two alternative measures, such as requiring individuals to dine in restaurants with only members of their household or restricting indoor dining in areas of the City where case counts are high; however, given the observations noted above, I do not believe that they will be either enforceable or effective, given the stage we have reached in COVID-19 resurgence.
  2. General Public: Drawing on experience from other jurisdictions, as well as our own successful experience in Ontario in controlling COVID-19 transmission during Wave 1, I recommend that individuals only leave their homes for essential activities, such as work, education, fitness, healthcare appointments, and to purchase food, with flexibility for up to two individuals from outside their household to provide social support if an individual lives alone.
  3. Recreation, Sports and Gyms: Given Toronto’s data concerning exposures, clusters, and outbreaks in fitness clubs, I strongly recommend that all indoor group classes in gyms be discontinued. I understand that recreation and sports teams that play indoors face a similar exposure risk; therefore, I recommend that indoor activities for recreation and sports teams be discontinued.
  4. Managing Public Health Measures in Large Venues: Given the evidence we have to date concerning exposures and outbreaks in large venues, some of which can have a capacity of more than 100, I have concerns about the current regulations that allow for 30% capacity. I understand that large venues are currently required to enter into an agreement with the Chief Medical Officer of Health for how they will operate. I further recommend that large venues be required to submit a plan to Toronto Public Health demonstrating how they will comply with public health measures, such as seating that ensures physical distancing and a method by which they will collect individual contact information.

I am requesting that you, as the Chief Medical Officer of Health for Ontario, use your legislative powers under the Health Protection and Promotion Act (HPPA) and the Provincial Emergency Order to enact these changes, or consider making the necessary legislative and/or regulatory changes to provide me as the Medical Officer of Health for the City of Toronto with the authority to take these actions. While I have some authority under Section 22 of the HPPA, I have received legal counsel that it would be unprecedented for a Medical Officer of Health to enact such broad changes, and such action may exceed my authority and therefore render me personally liable. I am therefore urging you to act in collaboration with the City of Toronto to implement these measures in as timely a fashion as possible.

As a part of my responsibility as the Medical Officer of Health for the City of Toronto, I have provided these recommendations to the Mayor of Toronto and the Chair of the Board of Health, in order for them to understand my concerns with the current trends in COVID-19 transmission in the City. For your consideration, I have attached to this letter some visual images of epidemiological analysis conducted by my team that reflect my concerns. I recognize that this is a challenging situation and I am available at your convenience to further discuss this request.

Yours truly,
Dr. Eileen de Villa
Medical Officer of Health

Attachment

Copy To:
City Manager, Chris Murray
Mayor John Tory
Chair of the Board of Health, Joe Cressy

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