Update on COVID-19 Projections

Science Advisory and Modelling Consensus Tables January 12, 2021 Key Findings

• Growth in cases has accelerated and is over 7% on the worst days. • Almost 40% of long-term care homes have active COVID-19 outbreaks. Since January 1st 198 LTC residents and 2 LTC staff have died of COVID-19. Forecasts suggest more deaths in wave 2 in long- term care than in wave 1. • COVID-19 ICU occupancy is now over 400 beds. Surgeries are being cancelled and the access to care deficit will continue to increase with real consequences for health. • Mobility, and contacts between people have not decreased with the current restrictions. Survey data show that the majority of Ontarians are helping limit spread by following them. However, case numbers will not decline until more of the population follows their example. • A new variant of concern of SARS-CoV-2 (B117) could drive much higher case counts, ICU occupancy and mortality if community transmission occurs. The doubling time for cases could drop by more than 2/3. This new variant is now in Ontario. • Without significant reductions in contacts, the health system will be overwhelmed and mortality will exceed the first wave totals before a vaccine has time to take effect.

2 Total new cases per 100,000 residents per week across PHUs Sept 17 Sept 25 Oct 16 Nov 7 Nov 23 Dec 14 Dec 26 In-person Restrictions Modified COVID-19 RESPONSE Toronto and Peel York and Province-wide classes for on bars and Stage 2 FRAMEWORK enter 28-day Windsor- lockdown all major restaurants begins in Durham, Halton, Eastern lockdown Essex enter 14 days N. ON 400 school York to Protect. Ottawa and lockdown 28 days S. ON boards York to Restrict. Peel to Sept 19 Oct 9 Control + local restrictions. Dec 4 Limits on Modified Toronto remains in Middlesex- social Stage 2 Modified Stage 2. 350 London + T-Bay gathering begins in to Restrict. sizes Toronto, Haliburton to Ottawa, Protect Windsor-Essex, 323 and Peel 300 Recent data subject to

day avg.) change -

250 Lambton, 253 Peel, 232

200 York, 197 Niagara, 182 Toronto, 180 Hamilton, 158 Durham, 145 Southwestern, 145 150 Waterloo, 145 Eastern, 142 Middlesex-London, 132 Wellington-Dufferin-Guelph, 128 Chatham-Kent, 126 Halton, 115 100 Haldimand-Norfolk, 106

Weekly new cases per 100,000 residents (7 Brant, 103 Ottawa, 80 Simcoe Muskoka, 72

50 CONTROL (cases ≥ 40) RESTRICT (cases ≥ 25) All Other PHUs, 32 PROTECT (cases ≥ 10) 0 Jan 2 Jan Oct 3 Sep 5 Dec 5 Aug 1 Aug 8 Nov 7 Oct 10 Oct 17 Oct 24 Oct 31 Sep 12 Sep 19 Sep 26 Dec 12 Dec 19 Dec 26 Aug 15 Aug 22 Aug 29 Nov 14 Nov 21 Nov 28 3 Data source: Case and Contact Management System, data up to January 8 COVID-19 testing % positivity across PHUs Sept 24 Oct 6 Nov 7 Nov 23 Dec 14 Dec 26 Testing Assessment COVID-19 RESPONSE Toronto and Peel York and Province-wide guidance Centres move FRAMEWORK enter 28-day Windsor- lockdown Durham, Halton, Eastern lockdown 14 days N. ON 16 update to advance Essex enter booking to Protect. Ottawa and lockdown 28 days S. ON York to Restrict. Peel to 15 Control + local restrictions. Dec 4 Toronto remains in Oct 1 Middlesex- Windsor-Essex, 14% 14 Modified Stage 2. London + T-Bay School & childcare to Restrict. screening guidance Haliburton to 13 change Protect Peel, 13% 12

11 day avg.) - York, 10% 10 Lambton, 10% Toronto, 10% 9 Chatham-Kent, 9%

8 Durham, 8% Southwestern, 7% 7 Waterloo, 7% Halton, 7% Eastern, 7% Hamilton, 6% 6 Middlesex-London, 6% Niagara, 6% Brant, 5% 5 Haldimand-Norfolk, 5% Wellington-Dufferin-Guelph, 5% Ottawa, 5% % positivity% of daily testing episodes (7 4 All Other PHUs, 4% Simcoe Muskoka, 3% 3 CONTROL (positivity ≥ 2.5%)

2 RESTRICT (positivity ≥ 1.3%) 1 PROTECT (positivity ≥ 0.5%) 0 Jan 2 Jan Oct 3 Sep 5 Dec 5 Aug 1 Aug 8 Nov 7 Oct 10 Oct 17 Oct 24 Oct 31 Sep 12 Sep 19 Sep 26 Dec 12 Dec 19 Dec 26 Aug 15 Aug 22 Aug 29 Nov 14 Nov 21 Nov 28 4 Data source: Ontario Laboratories Information System (OLIS), data up to January 4 Percent of COVID test results returned within 2 days across PHUs Sept 24 Oct 6 Nov 7 Nov 23 Dec 14 Dec 26 Testing Assessment COVID-19 RESPONSE Toronto and Peel York and Province-wide guidance Centres move FRAMEWORK enter 28-day Windsor- lockdown Durham, Halton, Eastern lockdown 14 days N. ON 110 update to advance Essex enter booking to Protect. Ottawa and lockdown 28 days S. ON York to Restrict. Peel to Control + local restrictions. Dec 4 100 Oct 1 Toronto remains in Middlesex- Toronto, 92% School & childcare Modified Stage 2. London + T-Bay Hamilton, 91% Halton, 90% screening guidance to Restrict. Peel, 86% change Haliburton to Middlesex-London, 86%

day avg.) 90 Eastern, 85% - Protect Chatham-Kent, 84% Ottawa, 84% Niagara, 84% Haldimand-Norfolk, 84% 80 Durham, 81% All Other PHUs, 77% Waterloo, 76% Brant, 75% York, 75% 70 Southwestern, 73% Windsor-Essex, 72% Simcoe Muskoka, 71% Wellington-Dufferin-Guelph, 66% 60 Lambton, 63%

% of testing episodes with results released within 2 daysof test (7 10

0 Jan 2 Jan Oct 3 Sep 5 Dec 5 Aug 1 Aug 8 Nov 7 Oct 10 Oct 17 Oct 24 Oct 31 Sep 12 Sep 19 Sep 26 Dec 12 Dec 19 Dec 26 Aug 15 Aug 22 Aug 29 Nov 14 Nov 21 Nov 28 5 Data source: Ontario Laboratories Information System (OLIS), data up to January 4 Weekly % positivity by age group

Weekly % positivity by age group

Legend:

Data Source: Ontario Laboratory Information System (OLIS), MOH – extracted from SAS VA Jan 10 Note: Includes all data submitted to OLIS up to January 7th 2021. The last six days are considered interim data (week 52) and subject to change 6 Weekly % positivity = total number of positive tests within the week (based on reported date)/COVID tests within the week Cases and cumulative mortality LTC increasing (198 resident and 2 staff deaths since January 1st)

Current status COVID-19 cases and deaths for LTC residents and staff 252 LTC homes have COVID-19 1500 outbreaks (40% of all homes) with 105 Daily Active Cases Residents outbreaks involving resident cases 1250 Outbreaks are occurring across almost Daily Active Cases Staff all public health units, with 1000 Cumulative deaths since Sept 1 91 outbreaks (37%) occurring in priority vaccination areas of Toronto, 750 Peel, York and Windsor-Essex Since January 1st, 198 LTC residents 500 have died of COVID-19 and 2 staff deaths have been reported 250 Forecasts suggest there will 0 be more LTC residents deaths in wave Sep 1 Sep Oct 1 Oct Nov Nov Dec 1 Dec Jan 1 2 than in wave 1 (1,815 total deaths) 15 15 1 15 15

Data Source: Ministry of Long-Term Care Tracker, Dec 19th extraction based on data reported up to 3:30 pm Jan 9th, 2021. 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 7 (i.e. iPHIS database) due to lags in reporting time. Projections: second wave cumulative LTC resident COVID-19 deaths >2,600 by Feb 14 in worst case scenario

Projected and actual cumulative LTC resident COVID-19 deaths (Sep 1, 2020-Feb 14, 2021) 3,000 2,639 projected deaths as of Feb 14, 2021 (worst case) Projected deaths 2,500 Actual cumulative deaths (MLTC tracker)

2,000 19 deaths Feb 14, 2021 1,119 actual deaths as of 1,500 Jan 9, 2021

1,000 Last of Last day forecast: CumulativeLTC resident COVID -

500

Predictions: MOH Capacity Planning and Analytics Division 8 Date Data: (Cumulative Deaths): MLTC Tracker Tool Long-term Care Outbreaks July 1, 2020

Public Health Unit 2226 Algoma Public Health Unit 2227 Brant County Health Unit 2230 Durham Region Health Department 2233 Grey Bruce Health Unit 2234 Haldimand-Norfolk Health Unit 2235 Haliburton, Kawartha, Pine Ridge District Health Unit 2236 Halton Region Health Department 2237 Hamilton Public Health Services 2238 Hastings & Prince Edward Counties Health Unit 2240 Chatham-Kent Health Unit 2241 Kingston, Frontenac and Lennox & Addington Health Unit 2242 Lambton Health Unit 2243 Leeds, Grenville & Lanark District Health Unit 2244 Middlesex-London Health Unit 2246 Niagara Region Public Health Department 2247 North Bay Parry Sound District Health Unit 2249 Northwestern Health Unit 2251 Ottawa Public Health 2253 Peel Public Health 2255 Peterborough Public Health 2256 Porcupine Health Unit 2257 Renfrew County & District Health Unit 2258 Eastern Ontario Health Unit 2260 Simcoe Muskoka District Health Unit 2261 Sudbury and District Health Unit 2262 Thunder Bay District Health Unit 2263 Timiskaming Health Unit 2265 Region of Waterloo, Public Health 2266 Wellington-Dufferin-Guelph Health Unit 2268 Windsor-Essex County Health Unit Size of outbreak (staff and residents) 2270 York Region Public Health 3895 Toronto Public Health 4913 Southwestern Public Health 5183 Huron Perth Health Unit

9 Long-term Care Outbreaks October 1, 2020

10 Long-term Care Outbreaks January 7, 2021

11 Despite some reduced mobility from “Grey Zone” restrictions, there was a pre-holiday spike

% change relative to January 2020 Analysis: UofT, St. Michael’s Hospital, ICES Data: Google 12 “Grey Zone” restrictions did not affect the proportion of people working from home; holiday decreases are not likely to persist

% change relative to January 2020 Analysis: UofT, St. Michael’s Hospital, ICES Data: Google 13 With current restrictions, almost 2/3 of the population are acting in a way that will decrease COVID-19 spread

• Are people in your neighbourhood physically distancing?

Occasionally or never Most of the time/sometimes All the time • In the last 4 weeks, how many people outside your household visited your house (meal, celebration, stay over)?

3 or more 1-2 None • And if so, did you observe restrictions?

Didn’t observe restrictions Observed restrictions 14 Survey: Fields Institute As happened in other jurisdictions, case growth continues under current levels of restrictions

Daily New Cases (Other Countries Aligned at 230/1M Population/Day) 45,000

ON 7%↑ 40,000

35,000

30,000

25,000

20,000 ON 5%↑

15,000

10,000 ON 3%↑

5,000 ON 1%↑ ON 0%↑

- 12-21 12-28 01-04 01-11 01-18 01-25 02-01 02-08

ON - Daily ON - 7-Day Mean ON 0%↑ (Constant) ON 1%↑ ON 3%↑ ON 5%↑ ON 7%↑ FRA GER NLD UK

Note: Ontario reached 23/100,000 cases between 1.5 Predictions informed by modeling from McMasterU, Fields Institute, COVID-19 ModCollab, PHO; and 3 months after these countries recent growth in new daily cases; reported cases in peer jurisdictions 15 Data (Observed Cases): covid-19.ontario.ca; https://ourworldindata.org Projections: COVID-19 ICU occupancy around 500 beds in mid- January, potentially over 1,000 beds in February in more severe, but realistic scenarios

3,500

ON 7%↑ 3,000

2,500 19 Patients (per Day) - 2,000 ON 5%↑

1,500

ON 3%↑ 1,000

ON 1%↑

500 ON 0%↑ ICU ICU Beds Occupied with COVID

150 beds 0

ON Observed ON Predicted ON 0%↑ (Constant) ON 1%↑ ON 3%↑ ON 5%↑ ON 7%↑

Predictions: COVID-19 ModCollab. 16 At 9% growth rate (not shown): >2,000 occupancy Feb 5 Data (Observed ICU Occupancy): CCSO COVID-19 hospitalizations and ICU admissions continue to climb

1500

1400 Over the past 4 weeks: 1300 72.2% increase in hospitalizations Confirmed COVID19 Acute Inpatients (excluding ICU) 61.2% increase in ICU patients 1200 Confirmed COVID19 ICU Patients 1100

1000

900

800

700

600

500

400

300

200

100

0 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 19-Dec 26-Dec 02-Jan 17 Data Sources: Daily Bed Census Summary COVID-19 Report + Critical Care Information System, extracted January 9 One quarter of hospitals have no ICU beds free, another quarter have only 1 or 2 beds free Percentage of Ontario L3 Medical Surgical ICU Beds Occupied on January 8, 2021, by Number of Available Beds 160%

140%

120%

100% 100% Occupancy 80% 85% 60% Occupancy

40%

20%

0% Percentage ofMSICU L3 Beds Occupied = Chatham-Kent 10 n = Hopital Montfort n 12= Mackenzie Health n = 30 Sault Area Hospital n 13 = Markham Stouffville n = 15 Mount Sinai Hospital 21 n = Scarborough General n = 29 Humber River Wilson n = 46 Lakeridge Health Ajax n = 13 Joseph Brant Hospital n 24 = LHSC Victoria Campus n = 31 Ross Memorial Hospital 9 n - Health Sciences North n = 14 Scarborough Centenary n 20 = LHSC University Campus n 25= Michael Garron Hospital n = 17 Guelph General Hospital n 10= Unity Health St. Joseph's 18 n = Stratford General Hospital n = 6 Scarborough Birchmount n = 15 Lakeridge Health Oshawa 32 n = Unity Health St. Michael's 29 n = Brantford General Hospital n 15= St. Mary's General Hospital n = 13 Quinte Healthcare Belleville n = 18 North York General Hospital n 23 = Woodstock General Hospital n 12 = Brockville Genearl Charles St n = 10 Trillium Mississauga n =Hospital 37 Georgian Bay General Hospital n 6 = Trillium Credit Valley Hospital n = 24 Cornwall Community Hospital n = 11 Cambridge Memorial Hospital n = 12 UHN TorontoUHN General Hospital n 38 = Queensway - Carleton Hospital n = 12 Pembroke Regional Hospital Inc. n = 9 UHN TorontoUHN Western Hospital n = 33 Grand River Kitchener Waterloo n 20= Orillia Soldiers Memorial Hospital n = 8 William Osler Etobicoke Campus n = 14 St. Thomas-Elgin General Hospital 8 n = William Osler Campus Brampton 24 n = Kingston Health Sciences Centre n 33 = Southlake Regional Health Centre n 18 = North Bay Regional Health Centre n 16 = The Hospital Ottawa Campus Civic n 29= Hamilton Health Sciences General n = 31 Sunnybrook Health Sciences Centre n 52 = Windsor Regional Ouellette Campus n = 20 Oakville Trafalgar Memorial Hospital n = 21 Royal Victoria Regional Health Centre n = 15 The Hospital Ottawa General Campus 29 n = Niagara Health System St. Catharines 14n = Peterborough Regional Hospital Drive n = 28 Grey Bruce Health Services Owen Sound n = 6 Niagara Health System Greater Niagara n = 15 St Joseph's Healthcare System Charlton n = 27 Windsor Regional Metropolitan Campus 19 n = Halton Healthcare Milton District Hospital n = 8 Bluewater Health Sarnia General Hospital n = 14 Hamilton Health Sciences Juravinski Hospital 23 n = Thunder Bay Regional Health Sciences Centre n 22 = 0 Free Beds 1 Free Bed 2 Free Beds 3+ Free Beds Other ICU Patients Patients with COVID-19 18 Access to care continues to decline below 2019 levels

Dec. 21 to 27 holiday fluctuation in surgical volumes

19 Daily mortality is increasing under current restrictions, doubling from 50 to 100 deaths per day between now and end of February

Assumption: continue current restrictions. Forecasting: McMasterU. 20 Data (Observed Deaths): CCM+ The Novel SARS-CoV-2 variant: B.1.1.7 appears to be much more easily transmitted

• Novel SARS-CoV-2 variant, Daily New Cases per 1 Million People (7-Day Average) B.1.1.7, emerged in southeast 1000 900 UK 800 Cases/1M Pop ~ 12,000 cases/Day for ON Population England in November 800 • Transmissibility: 56% ↑ (95% 700 credible interval 50-74%) 600 500 NLD • No increase in disease severity, 400

300 GER vaccines likely still effective FRA 200 ON

100

0 2-1-20 3-1-20 4-1-20 5-1-20 6-1-20 7-1-20 8-1-20 9-1-20 10-1-20 11-1-20 12-1-20 1-1-21

France Germany Netherlands United Kingdom Ontario

Sources: Public Health England Technical Reports; Davies NG et al (LSHTM) Sources: https://ourworldindata.org; CCM+ 21 If the SARS-CoV-2 variant B.1.1.7 spreads in the community, doubling time for cases could drop to 10 days in March

Assumptions: 1 case infected with B.1.1.7. from the UK entering Ontario mid-Oct, transmissibility of variant 56% ↑ than other circulating variants (based on UK data), continue current restrictions. 22 Predictions: QueensU Key components of hard lockdowns in peer jurisdictions Victoria, France (Fall) UK* Germany* Netherlands* Australia

Strict stay-at-home order / ✓ ✓ ✓ ✓ ✓ movement restrictions

Non-essential retail closed ✓ ✓ ✓ ✓ ✓ Bars, restaurants , gyms etc. closed ✓ ✓ ✓ ✓ ✓ Most workplaces closed ✓ ✓ ✓ ✓ ✓ Schools closed ✓ ✕ ✓ ✓ ✓ Mandatory masking outdoors ✓ ✓ ✕ ✕ ✕ Testing blitz in high risk areas ✓ ✕ ✕ ✕ ✕ Curfew ✓ ✓ ✕ ✓ ✕ Enforcement ✓ ✓ ✓ ✓ ✓

= fully imposed, = partially imposed, = not imposed, *Currently in lockdown ✓ ✓ ✕ 23 Key Findings

• Growth in cases has accelerated and is over 7% on the worst days. • Almost 40% of long-term care homes have active COVID-19 outbreaks. Since January 1st 198 LTC residents and 2 LTC staff have died of COVID-19. Forecasts suggest more deaths in wave 2 in long-term care than in wave 1. • COVID-19 ICU occupancy is now over 400 beds. Surgeries are being cancelled and the access to care deficit will continue to increase with real consequences for health. • Mobility, and contacts between people have not decreased with the current restrictions. Survey data show that the majority of Ontarians are helping limit spread by following them. However, case numbers will not decline until more of the population follows their example. • A new variant of concern of SARS-CoV-2 (B117) could drive much higher case counts, ICU occupancy and mortality if community transmission occurs. The doubling time for cases could drop by more than 2/3. This new variant is now in Ontario. • Without significant reductions in contacts, the health system will be overwhelmed and mortality will exceed the first wave totals before a vaccine has time to take effect.

24 Content provided by Modelling Consensus and Scientific Advisory Table members and secretariat

Beate Sander,* Peter Juni, Brian Schwartz,* Kumar Murty,* Upton Allen, Vanessa Allen, Nicholas Bodmer, Isaac Bogoch, Kevin Brown, Sarah Buchan, Yoojin Choi, Troy Day, David Earn, Gerald Evans, David Fisman, Jennifer Gibson, Anna Greenberg, Anne Hayes, Michael Hillmer, Jessica Hopkins, Jeff Kwong, Audrey Laporte, John Lavis, Gerald Lebovic, Brian Lewis, Linda Mah, Kamil Malikov, Antonina Maltsev, Doug Manuel, Allison McGeer, David McKeown, John McLaughlin, Sharmistha Mishra, Justin Morgenstern, Samira Mubareka, Laveena Munshi, Christopher Mushquash, Ayodele Odutayo, Shahla Oskooei, Samir Patel, Bill Praamsma, Justin Presseau, Fahad Razak, Paula Rochon, Laura Rosella, Arjumand Siddiqi, Chris Simpson, Arthur Slutsky, Janet Smylie, Nathan Stall, Ashleigh Tuite, Jennifer Walker, Tania Watts, Ashini Weerasinghe, Scott Weese, Xiaolin Wei, Jianhong Wu, Diana Yan, Emre Yurga

* Chairs of Scientific Advisory or Modelling Consensus Tables