Local medical officers of health across the province are banding together to create their own framework to inform decisions about reopening in their regions — a move that one says stemmed from the desire to "have some influence over the pace at which the province reopens" and that a Toronto-based epidemiologist is applauding.
Dr. Charles Gardner, medical officer of health for the Simcoe Muskoka District Health Unit, said the development of a local framework, which was first reported in the <a href="https://www.thestar.com/opinion/2020/05/27/as-ontario-goes-with-one-size-fits-all-medical-officers-of-health-join-forces-to-take-back-some-local-control.html" target="_blank" rel="noopener noreferrer">Toronto Star</a>, was spearheaded by some public health officials — like Dr. Lawrence Loh, interim medical officer of health for the Peel region — in areas that have been hit hard by COVID-19.
"The desire is there for health units that have a particularly heavy burden of illness from COVID-19 to have some influence over the pace at which the province reopens," Gardner told QP Briefing on May 27.
Some health units, such as in the Greater Toronto Area, he said, are concerned about their higher per-capita number of COVID-19 cases and want to make sure "the pace is manageable" as the province looks to reopen.
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For instance, according to provincial data up until May 27, Peel Public Health has reported 4,150 cases of COVID-19, which means around 258 people per every 100,000 tested positive. The incidence of 75.6 people per every 100,000 in Gardner's region is much lower, but only slightly at the Windsor-Essex County Health Unit, which reported an incidence rate of 216.6 per 100,000 people.
Dr. Wajid Ahmed, medical officer of Health for the Windsor-Essex County Health Unit, said the provincial framework offers "high level" guidelines, but there was a need for more specific indicators.
"Recognizing that (in) the entire province we have many many different regions...in addition to what the provincial indicators or provincial data looks like, there’s also a need for some kind of local data that we can collect and use to guide our local situation," Ahmed said. "I think it will support the work of the province and also provide us with valuable information locally to help us do the work that we are doing."
The provincial government released its framework for reopening the province on April 27, which included some general criteria for easing public health measures.
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Gardner, who is also part of the province's public health measures table that is advising Chief Medical Officer of Health Dr. David Williams, said the local framework is "well-aligned" with that of the province, but is just more specific.
For example, the province's framework includes the criteria of a "consistent two-to-four week decrease in the number of new daily COVID-19 cases," whereas the local framework suggests more specifics like using a seven-day moving average of daily new cases of COVID-19 in the community and the percentage of cases that are not linked to a known source, Gardner said.
He said indicators of a region's health system capacity would include the percentage of acute care beds, intensive care beds and intensive care ventilators that are occupied.
A presentation from Dr. Loh to the Peel region council on Thursday showed some of the metrics he's using including the need to keep 15 per cent of acute care beds in the region available.
<img class="alignright wp-image-372933 size-large" src="https://www.qpbriefing.com/wp-content/uploads/2020/05/Screen-Shot-2020-05-28-at-2.40.47-PM-843x451.png" alt="" width="843" height="451" srcset="https://old.qpbriefing.com/wp-content/uploads/2020/05/Screen-Shot-2020-05-28-at-2.40.47-PM-843x451.png 843w, https://old.qpbriefing.com/wp-content/uploads/2020/05/Screen-Shot-2020-05-28-at-2.40.47-PM-405x217.png 405w, https://old.qpbriefing.com/wp-content/uploads/2020/05/Screen-Shot-2020-05-28-at-2.40.47-PM-768x411.png 768w, https://old.qpbriefing.com/wp-content/uploads/2020/05/Screen-Shot-2020-05-28-at-2.40.47-PM.png 1096w" sizes="(max-width: 843px) 100vw, 843px" />
The document also shows that Peel has not seen a 14-day decrease in the seven-day moving average of cases not tied to institutional outbreaks, but rather has seen an increase in this.
"My sense of it is the impetus for creating this framework came from those health units that would like to slow things down, that the province is moving at a certain pace and for those that were more concerned that they can’t keep up, that this would lead to further potential increases in the rate of cases," said Gardner.
He said the plan was submitted to provincial officials earlier this week, but that he had notified them more than a week ago that this was being developed. There has been some discussion about the feasibility of a more regional approach, he said.
"There’s some consideration now about what should be advised to the chief medical officer of health about (the) potential for a regional approach to decision-making," Gardner said.
Responding to questions on Wednesday about whether the province should have outlined more specific metrics in its own document or consulted further with local medical officers of health, Williams rejected the idea saying that some of them are part of the table that put together the provincial metrics.
"I see it quite differently," he said. "The document they developed mirrors all those metrics as we’ve laid out...they're hoping to have some other ones added to that, it would be very much local health unit ones," he said. "I saw it as more of as a positive thing, much like people see a direction saying, okay how do we get ourselves together to support that even better at the local level."
He said he viewed it more as local medical officers of health trying to "support" the province's framework. So for example if regions needed to limit any reopening measures, they would "do it in a way that would support the provincial programs; at the same time, be able to explain to the public and to their municipal councils that they're working with to be able to give a reason of why they were doing this."
Health Minister Christine Elliott didn't oppose the idea during a press conference on Wednesday. She said while Williams has helped guide the province's reopening, local medical officers of health "take their own view of things based on their own local conditions and they can then decide whether they want to open things up to the full extent allowed by Stage 1 or if they choose to move more slowly."
"We’re still receiving information from them, we’re listening to what they’re telling us, that’s all going forward to the chief medical officer of health and the public health officers at the command table, and that will help guide us to Stage 2 both in terms of what could be included in Stage 2 in terms of opening up of businesses and organizations, but also when to do that."
And while local public health units could use some of the outlined thresholds to determine whether to slow down the easing of public health restrictions, there's also the question of allowing areas that have very few COVID-19 cases to reopen sooner — something the premier has often said he's not in favour of.
"People travel, cottage country can see on a long weekend half a million cottagers go up to cottage country coming form the city, coming from the GTA," said Premier Doug Ford on Wednesday. "I always say we need to stick together, we need to work together as a province and I think we’re moving along fairly well."
But Colin Furness, an epidemiologist and assistant professor at the Faculty of Information at the University of Toronto, said there will always be a risk of people moving around the province with the virus.
"It could happen right now; we don’t have a curfew," he said, adding that people need to understand that even though businesses might be open in their community, they still need to wear masks and practice physical distancing.
"The risk that the premier mentioned is real, but it doesn’t justify saying, 'Oh there’s people coughing in Toronto, we better shut...all the stores in Thunder Bay,'" he said.
Furness said there are ways to clearly communicate regional differences and suggested an interactive website that allows people to click on their region and see what restrictions are in place.
Ahmed said "if we can get to a consistent approach that would be great, and having very little variation could still be an option."
He said they're not looking to create confusion, but rather protect their communities.
"One of my responsibility is to protect and promote the health of my community’s wellbeing and recognizing that the cases and the local situation varies from region-to-region," he said. "So for me, some of these data along with additional indicators that we will be looking at which would be very specific for my region...I think that would definitely be helpful for me to understand my local situation."
Furness said the approach from the local medical officers of health "makes sense."
"I have questioned from the start the premise from the premier’s office that everyone in Ontario has to have the same timetable," Furness said.
He said that because regions have different levels of community spread, some parts of Ontario probably waited longer than they needed to before starting to reopen and others, like the GTA, opened too soon.
"Being able to localize a reaction is an excellent idea, I applaud the medical officers of health for banding together to do that, because they’re really pushing back," he said.
"I don’t see where data has played any role in the decision-making that’s happened so far," Furness argued, saying that whether or not this comes from the local medical officers of health, "someone’s got to start using science and data."
While the province started seeing a dip in the five-day rolling average two weeks prior to Ontario entering Stage 1 of its reopening on May 19, the average started to rise again on May 15.
"I’m glad the medical officers of health are stepping up, I’m glad they’re doing that…I see a big gap between the expertise that’s available and the expertise that’s being used in decision-making and I think they’re poised to bridge that gap," Furness said.
For his part, Williams said the province is using a large number of metrics including the provincial ICU and hospitalization usage, but that his local counterparts could offer some more regional-level data.
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-With files from Jessica Smith Cross

Local medical officers of health want ‘some influence over the pace at which the province reopens’

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