Update on COVID-19 Projections Science Advisory and Modelling Consensus Tables December 21, 2020 CONFIDENTIAL - DO NOT CIRCULATE Key Findings • Cases continue to grow and overall case levels are twice the “red” level. Percent positivity is flattening. Our ability to control case growth is still precarious. • Continuing case growth will increase outbreaks in long-term care homes and other congregate settings. • Under all scenarios, ICU occupancy will be above 300 beds within 10 days. Worst case scenarios show occupancy above 1,500 beds by mid-January. • Based on experience in France and Australia, “hard lock-downs” of 4–6 weeks can reduce case numbers in Ontario to less than 1,000 per day and possibly much lower with increased testing and support. • With lower case numbers we can maintain safe ICU care for COVID-19 and non- COVID-19 patients who require it. • As noted in previous briefings, public health restrictions will require more resources (e.g. testing, isolation/quarantine support) in communities and essential service workplaces where exposure is higher. 2 All Other PHUs, 26 Haldimand-Norfolk, 45 Middlesex-London, 52 Ottawa, 30 Peel, 188 Simcoe Muskoka, 50 Wellington-Dufferin-Guelph, 87 Windsor-Essex, 177 Hamilton, 109 Brant, 64 Halton, 69 Niagara, 67 Waterloo, 80 Durham, 82 York, 102 Toronto, 128 PROTECT (cases ≥ 10) RESTRICT (cases ≥ 25) CONTROL (cases ≥ 40) Southwestern, 65 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 Aug 1 Aug 8 Aug 15 Aug 22 Aug 29 Sep 5 Sep 12 Sep 19 Sep 26 Oct 3 Oct 10 Oct 17 Oct 24 Oct 31 Nov 7 Nov 14 Nov 21 Nov 28 Dec 5 Dec 12 Weekly new caes per 100,000 residents (7-day avg.) Total new cases per 100,000 residents per week across PHUs Data source: Case and Contact Management System, data up to December 17 Oct 9 Modified Stage 2 begins in Toronto, Ottawa, and Peel Sept 17 In-person classes for all major school boards Sept 25 Restrictions on bars and restaurants Oct 16 Modified Stage 2 begins in York Nov 7 COVID19 RESPONSE FRAMEWORK Durham, Halton, Eastern to Protect. Ottawa and York to Restrict. Peel to Control + local restrictions. Toronto remains in Modified Stage 2. Nov 23 Toronto and Peel enter 28x-day lockdown Dec 14 York and Windsor￾Essex enter lockdown Dec 4 Middlesex￾London + T-Bay to Restrict. Haliburton to Protect Sept 19 Limits on social gathering sizes 3 Brant, 2.2% Halton, 4.0% Hamilton, 4.3% Middlesex-London, 3.0% Niagara, 2.8% Peel, 8.1% Simcoe Muskoka, 1.9% Wellington-Dufferin-Guelph, 3.3% Windsor-Essex, 6.6% Haldimand-Norfolk, 2.6% Durham, 3.2% Ottawa, 1.3% Southwestern, 2.5% Toronto, 5.1% York, 6.0% All Other PHUs, 2.6% PROTECT (positivity ≥ 0.5%) RESTRICT (positivity ≥ 1.3%) CONTROL (positivity ≥ 2.5%) 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 Aug 1 Aug 8 Aug 15 Aug 22 Aug 29 Sep 5 Sep 12 Sep 19 Sep 26 Oct 3 Oct 10 Oct 17 Oct 24 Oct 31 Nov 7 Nov 14 Nov 21 Nov 28 Dec 5 Dec 12 % positivity of daily testing episodes (7-day avg.) COVID-19 testing % positivity across PHUs Data source: Ontario Laboratories Information System (OLIS), data up to December 14 Sept 24 Testing guidance update Oct 6 Assessment Centres move to advance booking Oct 1 School & childcare screening guidance change Nov 7 COVID19 RESPONSE FRAMEWORK Durham, Halton, Eastern to Protect. Ottawa and York to Restrict. Peel to Control + local restrictions. Toronto remains in Modified Stage 2. Nov 23 Toronto and Peel enter 28-day lockdown 4 Brant, 49% Halton, 70% Hamilton, 84% Middlesex-London, 61% Niagara, 79% Peel, 75% Simcoe Muskoka, 60% Wellington-Dufferin-Guelph, 47% Windsor-Essex, 54% Haldimand-Norfolk, 53% Durham, 58% Ottawa, 85% Southwestern, 61% Toronto, 88% York, 83% All Other PHUs, 74% 0 10 20 30 40 50 60 70 80 90 100 110 Aug 1 Aug 8 Aug 15 Aug 22 Aug 29 Sep 5 Sep 12 Sep 19 Sep 26 Oct 3 Oct 10 Oct 17 Oct 24 Oct 31 Nov 7 Nov 14 Nov 21 Nov 28 Dec 5 Dec 12 % of testing episodes with results released within 2 days of test (7-day avg.) Percent of COVID test results returned within 2 days across PHUs Data source: Ontario Laboratories Information System (OLIS), data up to December 14 Sept 24 Testing guidance update Oct 6 Assessment Centres move to advance booking Oct 1 School & childcare screening guidance change Nov 7 COVID19 RESPONSE FRAMEWORK Durham, Halton, Eastern to Protect. Ottawa and York to Restrict. Peel to Control + local restrictions. Toronto remains in Modified Stage 2. Nov 23 Toronto and Peel enter 28-day lockdown 5 Weekly % positivity by age group Legend: Data Source: Ontario Laboratory Information System (OLIS), MOH – extracted from SAS VA December 19. Note: Includes all data submitted to OLIS up to December 16, 2020. The last six days are considered interim data (week 49) and subject to change Weekly % positivity = total number of positive tests within the week (based on reported date)/COVID tests within the week Weekly % positivity by age group 6 0 5,000 10,000 15,000 20,000 25,000 30,000 Number of Cases per Day (other countries aligned at 13/100,000/day) ON 2nd wave - Daily ON 2nd wave - 7-Day Average ON 0%↑ (Constant) ON 1%↑ ON 3%↑ ON 5%↑ ON 7%↑ France Germany Netherlands UK Michigan As in other jurisdictions, case growth continues despite soft restrictions 7 ON 3%↑ ON 1%↑ ON 0%↑ ON 7%↑ Predictions informed by modeling from McMasterU, COVID-19 ModCollab, PHO; recent growth in new daily cases; reported cases in peer jurisdictions Data (Observed Cases): covid-19.ontario.ca; https://ourworldindata.org; covidtracking.com Note: Ontario reached 13/100,000 cases between 1.5 and 3 months after these countries ON 5%↑ 0 100 200 300 400 500 600 700 800 900 1000 01-Aug 08-Aug 15-Aug 22-Aug 29-Aug 05-Sep 12-Sep 19-Sep 26-Sep 03-Oct 10-Oct 17-Oct 24-Oct 31-Oct 07-Nov 14-Nov 21-Nov 28-Nov 05-Dec 12-Dec Patients in Inpatient Beds with COVID19 (excluding ICU) Patients in ICU with COVID-Related Critical Illness 8 Data Sources: Daily Bed Census Summary COVID-19 Report + Critical Care Information System. Extracted via MOH SAS VA December 18. Over the past 4 weeks: 69.3% increase in hospitalizations 83.1% increase in ICU patients COVID-19 hospitalizations and ICU admissions continue to climb 0 300 600 900 1,200 1,500 1,800 COVID-19 Patients in ICU / Day ON Observed ON Predicted ON 0%↑ (Constant) ON 1%↑ ON 3%↑ ON 5%↑ ON 7%↑ Projections: ICU occupancy > 300 beds end of Dec, > 1,500 mid Jan in more severe scenarios 9 ON 0%↑ ON 1%↑ ON 3%↑ ON 5%↑ ON 7%↑ Predictions: COVID-19 ModCollab. Data (Observed ICU Occupancy): CCSO 150 beds High ICU occupancy threatens quality of care • High occupancy → Threatens timely access for all patients needing admission → Delayed access ↑ mortality (Gabler 2013, Harris 2018) • Acceptable occupancy threshold varies by ICU size (Green 2002) • 30 bed ICU: < 75% occupancy level • 15 bed ICU: < 65% occupancy level 10 Data: ICES; https://doi.org/10.5034/inquiryjrnl_39.4.400 pD = probability of delayed admission to hospital bed 0 100,000 200,000 300,000 400,000 500,000 600,000 Non-Elective Elective 85% of total 15% of total ICU Bed Days Distribution, Ontario, FY 2018/19 Directive #2 LTC Action Plan Surgical Restart Resume LTC (re)admissions 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 -100% -80% -60% -40% -20% 0% 20% 40% 60% 80% COVID-19 Active Cases 2020 vs 2019 (%) COVID Volumes Diagnostic Imaging (MRI/CT) Surgery ALC (Acute) 0% Line (No Change vs 2019) ER ER (Projected from triage volumes in eCTAS) Occupancy Rate Access to care continues to decline below 2019 levels 11 Active COVID-19 Cases Community spread drives outbreaks in LTC homes 12 LTC Home cases and outbreaks Data Source: Ministry of Long Term Care Tracker, Dec 19th extraction based on data reported up to 3:30 pm Dec 18th, 2020. Data are self-reported by the long-term care homes to the Ministry of Long-Term Care. Daily case and death figures may not immediately match the numbers posted by the local public health units (i.e. iPHIS database) due to lags in reporting time. Current status 145 Long term care (LTC) homes currently in outbreak, with 1,639 active confirmed cases in these homes 795 resident, 902 staff active cases in total 2,481 cumulative resident deaths, 8 cumulative staff deaths as of Dec 18th 83% of resident deaths in wave 2 have occurred since Nov 1 49 of the 145 homes in outbreak are based on 1 staff case There have been 633 resident deaths since Sept 1st , 100 of which have been in the past 7 days 13 Cases and cumulative mortality LTC increasing (100 deaths in the past 7 days) 0 100 200 300 400 500 600 700 800 900 Sep 1 Sep 15 Oct 1 Oct 15 Nov 1 Nov 15 Dec 1 Dec 15 COVID-19 cases and deaths for LTC residents and staff Daily Active Cases Residents Daily Active Cases Staff Cumulative deaths since Sept 1 Daily mortality is increasing and based on forecasting will continue to increase Forecasting: McMasterU. 14 Data (Observed Deaths): CCM+ maximum likelihood estimate 5% confidence band 95% confidence band Number of Deaths • Reported Number of Deaths - Predicted Number of Deaths Other jurisdictions are 1 ½ - 3 months ahead of us Most have used some form of hard lockdown 15 ON currently (~133 cases/1M/Day) 130 / 1 Million Data: https://ourworldindata.org Peer Jurisdictions with “Hard Lockdowns” see dramatic reductions in case numbers Victoria, Australia France - 100 200 300 400 500 600 700 800 900 1,000 6-1-20 7-1-20 8-1-20 9-1-20 10-1-20 11-1-20 12-1-20 Cases / 1M Population / Day Cases/1M population/Day (7-day Average) Victoria - 100 200 300 400 500 600 700 800 900 1,000 6-1-20 7-1-20 8-1-20 9-1-20 10-1-20 11-1-20 12-1-20 Cases / 1M Population / Day Cases/1M population/Day (7-day Average) France Hard Lockdown (~12-16 Weeks) Hard Lockdown (~7 Weeks) 50% ↓ Cases : ~ 3 Weeks 75% ↓ Cases: ~ 4.5-6 Weeks 90% ↓ Cases: ~ 7 Weeks (Victoria) Data: https://ourworldindata.org 16 - 1,000 2,000 3,000 4,000 5,000 6,000 Cases / Day Predicted Number of Cases / Day ON 0%↑ ON 3%↑ ON 5%↑ ON Predictions: The effect of lockdowns varies with the starting case numbers and length of lockdown 17 4-Week Hard Lockdown 6-Week Hard Lockdown Predictions: COVID-19 ModCollab. Threshold ON 0%↑ ON 3%↑ ON 5%↑ < 1,000 Cases / Day Jan 15 Jan 26 Feb 5 < 500 Cases / Day Jan 29 Feb 12 Feb 24 < 100 Cases / Day Mar 22 Apr 19 May 8 Manitoba’s lockdown was the most stringent and had the biggest impact on mobility • The mobility index is the estimated proportion of time spent outside of home – 100 represents January 2020 levels. Manitoba has had a strict lockdown since November 12 Data from: https://www.google.com/covid19/mobility/ 18 Earlier lockdowns will reduce cases 19 - 500 1,000 1,500 2,000 2,500 3,000 3,500 12-21-20 12-23-20 12-25-20 12-27-20 12-29-20 12-31-20 1-2-21 1-4-21 1-6-21 1-8-21 1-10-21 1-12-21 1-14-21 1-16-21 1-18-21 1-20-21 1-22-21 1-24-21 1-26-21 1-28-21 1-30-21 2-1-21 2-3-21 2-5-21 2-7-21 2-9-21 2-11-21 2-13-21 2-15-21 2-17-21 2-19-21 2-21-21 2-23-21 2-25-21 2-27-21 3-1-21 3-3-21 3-5-21 3-7-21 3-9-21 3-11-21 3-13-21 3-15-21 3-17-21 3-19-21 3-21-21 3-23-21 3-25-21 3-27-21 3-29-21 3-31-21 Cases / Day Prevented Daily Number of Cases Prevented by Starting Hard Lockdown Dec 21 vs. Dec 28 ON 0%↑ ON 3%↑ ON 5%↑ ON 0%↑ ON 3%↑ ON 5%↑ Dec 21 - Dec 31, 2020 801 1,658 2,601 Dec 21 - Jan 31, 2021 11,260 26,709 45,147 Total Number of Cases Prevented Predictions: COVID-19 ModCollab. Key Findings • Cases continue to grow and overall case levels are twice the “red” level. Percent positivity is flattening. Our ability to control case growth is still precarious. • Continuing case growth will increase outbreaks in long-term care homes and other congregate settings. • Under all scenarios, ICU occupancy will be above 300 beds within 10 days. Worst case scenarios show occupancy above 1,500 beds by mid-January. • Based on experience in France and Australia, “hard lock-downs” of 4–6 weeks can reduce case numbers in Ontario to less than 1,000 per day and possibly much lower with increased testing and support. • With lower case numbers we can maintain safe ICU care for COVID-19 and non- COVID-19 patients who require it. • As noted in previous briefings, public health restrictions will require more resources (e.g. testing, isolation/quarantine support) in communities and essential service workplaces where exposure is higher. 20