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'This is NOT a blip': COVID-19 cases are accelerating in Canada. Should we be worried?

Federal Health Minister Patty Hajdu walks past a COVID-19 health advisory sign on Tuesday, September 15, 2020.

Confirmed COVID-19 infections are accelerating upwards, hospital and intensive care admissions in some cities are rising modestly and winter isn’t even here yet. Should we be worried?

Yes and no, experts say.

Canada reported 1,351 new cases Monday, numbers not seen since late May. Across Canada, 290 people were reported hospitalized as of Tuesday morning, with 68 in ICUs. And Canada’s Health Minister Patty Hajdu on Tuesday talked about targeted lockdowns to address rising COVID cases in several provinces.

“To be clear, once #COVID19 enters the hospital & ICUs, it signals UNCONTROLLED community transmission,” Dr. Abdu Sharkawy, an infectious diseases specialist with Toronto’s University Health Network tweeted this weekend. He was responding to UHN’s president and CEO Dr. Kevin Smith’s expressed alarm on Saturday over a rise in the number of people with the pandemic virus admitted to UHN hospitals — from zero for “some weeks,” to seven — most of them in ICUs.

“This is NOT a blip. It’s real,” Sharkawy warned.

Ontario reported 313 new cases on Monday, the bulk from three regions — Toronto, Peel and Ottawa. When the province announced on March 12 that it was ordering all schools closed for two weeks after the March break, Ontario had logged just 17 new cases.

Though the ICU numbers are relatively small, hospital and intensive care admissions lag infections, anywhere from four to eight weeks. “If you’re reacting to hospitalizations,” epidemiologist David Fisman tweeted Tuesday, “you’ve missed the boat.”

There were more roadblocks to testing back in March and April —  a global shortage of swabs restricted testing to the seriously ill and vulnerable groups. But community spread then was also minimal, said infectious diseases physician Dr. Andrew Morris. “We were still thinking about travel primarily. Not anymore.”

Ontario officials have pinned the province’s surge largely on extended family gatherings and indoor social gatherings, but, experts ask, how certain can they be when, in roughly half of new cases, the source of exposure is “unknown?”

“That is worrisome: it means we aren’t even close to containing spread,” Morris wrote in an email.

Yet, while cases are curving upwards, there hasn’t been a proportionate increase in deaths. Deaths are the longest lagging indicator, but it’s also true hospitalized people are dying less frequently. Doctors are better able to manage the disease when it does end up in hospitals. And younger people under 40 who are less likely to get seriously ill from the pandemic virus now make up the majority of new cases.

According to a large review from France published in the journal Science, researchers estimate 2.9 per cent of infected are hospitalized and 0.5 per cent of those infected die, ranging from 0.001 per cent aged under 20, to 8.3 per cent aged 80 and older.

But deaths shouldn’t be the only metric when considering the impact of the pandemic. “There has been a lack of appreciation for the subtle and more insidious effects of this virus that isn’t captured by mortality or hospital admission rates,” Sharkawy said in an interview. “There are countless cases of younger people who don’t necessarily require hospital admission but are suffering debilitating consequences of this infection,” he said — energy levels that haven’t recovered, breathing difficulties, problems concentrating.

In a study published Tuesday by the journal Neurology , Western University researchers reported that about two in every 100 patents admitted to hospital with COVID-19 will suffer a stroke, and 35 to 45 per cent of them will die as a result of both stroke and COVID. In people under 50, nearly half of those who had a stroke had no other visible symptom of the virus. Many didn’t have a single risk factor — “they were totally healthy people,” said Western stroke neurologist Dr. Luciano Sposato. A high proportion had large clots in the main arteries of the brain.

It’s worrisome seeing new hospital and ICU admissions, said Morris, professor of medicine at the University of Toronto. “In many jurisdictions, early on in their second waves they really didn’t show overflow to hospitals and ICUs — it lagged considerably.”

But he believes we have the ICU and ventilator capacity, should we need it. And while cases are rising in three hotspots in Ontario, most other public health units had fewer than 10 new cases Monday, and many had none.

Still, it is dangerous to assume anything, especially if a COVID surge piggybacks with the flu. “It’s the natural history with this disease, where once you reach a critical threshold with community transmission, at some point those that are going to be vulnerable….end up arriving in the ER and in the ICU,” said Sharkawy.

With schools starting back up again and businesses largely open, the challenges are more difficult than in March or April, because we’re starting at a baseline of greater exposure risk, he said. “And I think people really need to recognize that.”

In March, there was a “captive sense of fear” and dread, Sharkawy said, an uncertainty of what lay ahead. We averted “catastrophe” by following public health advice.

Now, “there’s been a sense of smugness, frankly, that in Canada, because we’ve got decent leadership and very strong public health guidance comparatively to our neighbours to the south, that somehow we’ve gotten away with this and there is nothing else we need to concern ourselves with.

“That’s an extremely dangerous attitude to have, and one we hold at our peril,” Sharkawy said.

But others say we need to avoid alarming people across the board. “People in areas where there is a higher risk, they should be made aware,” said Dr. Dominik Mertz, an infectious diseases expert at McMaster University in Hamilton.

He worries about complacency and pandemic fatigue. “How to convince people at this point of time? That’s what everybody is struggling with.”

Instead of throwing everything we have at COVID-19 to win time, a more strategic response is needed, Mertz said. There are still gaps, but “we’ve learned a lot about this virus, we have learned about the transmission patterns.” In his popular weekly newsletter to family and friends , Morris recommends cordon sanitaire —  limiting movement in and out of affected jurisdictions to prevent spread — closing indoor dining, bars and nightclubs and cease testing people with no symptoms or no known contacts.

But what is the magical moment when aggressive measures are needed? Mertz isn’t convinced we’re there yet. “We have the option for a more surgical or precise intervention, and give that a chance to work to get those hotspots under better control.”

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