At least 860 people have died of COVID-19 in an Ontario hospital outbreak, according to a new public health report that reveals a far larger death toll than had been previously known.
The total, contained in a Public Health Ontario (PHO) epidemiological summary updated earlier this month, means Ontario hospitals have been the province’s second-deadliest setting for COVID-19 outbreaks in the pandemic, behind long-term-care homes and ahead of retirement homes — but with little of the public reckoning seen in those sectors.
“There’s no other way to depict this other than a completely unmitigated tragedy,” said Dr. Abdu Sharkawy, an infectious diseases consultant at the University Health Network and assistant professor of medicine at the University of Toronto. The death toll highlights the changes hospitals need to make to better control the spread of respiratory diseases now and in the future, he added.
Another serious respiratory disease is “invariably, inevitably going to be coming our way at some point in the future,” he said.
In recent months, Ontario’s public health officials have defended the province’s hospital safety protocols against criticism they have not been changed to reflect growing evidence of COVID’s airborne risk; the province’s health officials remain steadfast this was the right call.
The province’s key guidance on protecting hospitals from the virus relies instead on familiar “droplet and contact” protections — exemplified by surgical masks, face shields and physical distancing — and mandates stricter airborne protocols — such as the exclusive use of N95 respirators and negative-pressure isolation rooms — only for specific medical procedures.
Marlene Chorley, whose father Rob Chorley died after catching COVID at Mississauga Hospital last February, on Wednesday said it was “shocking” to learn so many others have suffered the same fate.
The Chorley family says they were told little about how Rob, a 67-year-old retired Air Canada worker, could have contracted the virus in hospital. What they do know is that he was exposed on Feb. 22 while in hospital to have a small tumour removed from his spine and within days of testing positive, he started to have trouble breathing. He died at Oakville Trafalgar Memorial Hospital on March 22.
“These are statistics, but these are real people that are dying,” she said.
The province’s guidelines are formulated in a document known as “Directive 5,” which is supported by the large majority of infection prevention and control experts who manage outbreak response inside Ontario hospitals. Critics, however, say the rules are at odds with the latest research.
Last month, a major review in the journal Science pointed to several lines of evidence that each offer “strong and unequivocal evidence for airborne transmission.”
In a new peer-reviewed study published in Clinical Infectious Diseases this week, a separate team of U.S. researchers was able to collect and culture COVID-19 aerosols from the breath of people wearing surgical or cloth masks, a finding that suggests “that the virus is evolving toward more effective dissemination through aerosols and demonstrates that infectious virus can escape from loose-fitting masks.”
The authors conclude: “Therefore, until vaccination rates are very high, continued layered controls and tight-fitting masks and respirators will be necessary.”
In a written response to the Star’s questions, Bill Campbell, a spokesperson for the Ministry of Health emphasized that hospitals are required “to adhere to all components of Directive 5 on required precautions and procedures for health and safety and the use of personal protective equipment.”
Campbell noted the province’s chief medical officer of health has issued a directive mandating hospitals to have a COVID-19 vaccination policy for employees. Ontario is “doing better than other jurisdictions because we have kept public health measures in place, including maintaining indoor masking and capacity limits, while continuing to roll out first and second doses as part of our last-mile strategy,” he said.
Hospital outbreaks are declared after two or more patients contract the virus within a specified area, such as a unit or floor, and both could have reasonably been infected in the hospital. Campbell noted that the PHO report refers to all outbreak-associated cases linked to a declared hospital outbreak, but may not necessarily reflect where the person acquired the infection.
The fact Ontario’s hospital infection control experts have not acted on the evidence for airborne spread shows they are “absolutely in denial,” said Colin Furness, an infection control epidemiologist at the University of Toronto. The infection control field is “going to be on a multi-year reckoning when COVID is over and done,” he said.
“There’s an avalanche of evidence now from everywhere,” Sharkawy added.
Unlike with long-term care, Ontario does not publish a detailed list of hospital outbreaks on a facility-by-facility basis, making it impossible for the Star to do the kind of in-depth analysis it has done on COVID outcomes in nursing homes.
The province first published topline data on COVID deaths in hospital outbreaks earlier this year, revealing there were 297 deaths among patients who caught the virus in a hospital outbreak from the start of the pandemic to Dec. 26, 2020.
After this, the Star was able to use local health unit data to confirm a total of at least 500 deaths in Ontario hospital outbreaks through late June 2021 — a finding that revealed hundreds more patients had died after catching COVID in a hospital outbreak in Waves 2 and 3.
That analysis was missing data from several of the province’s larger health units, and the new PHO report reveals a substantially larger toll over a similar period — 6,292 infections and 860 deaths from the beginning of the pandemic through July 5, 2021, near the end of the third wave.
The difference since the earlier PHO report — 563 patient deaths — again highlights that hundreds more have died after catching COVID inside an Ontario hospital since Directive 5 was last substantively changed last fall, and after the arrival of the more transmissible Alpha and Delta variants. (The latest number is likely still an undercount, as it does not include any developments in the last two months).
The new PHO report also finds Ontario’s hospital outbreaks have tended to be larger and longer-lasting than reported outbreaks in long-term care and retirement homes, the other settings the province classifies as “congregate care.”
Campbell, the ministry spokesperson, noted that the two PHO reports reflect two very different times during the pandemic. “The original PHO report reflects a period of time prior to the Delta variant, when COVID-19 was less transmissible,” he said. “The more recent report reflects the high transmissibility of the Alpha and Delta variants in the community.”
In May, the province defeated a court challenge calling on the chief medical officer of health to update Directive 5 in response to the virus’ airborne risk. Among other things, the Ontario Nurses’ Association asked a judge to enforce a mandate to use N95 respirators, which are rated to filter smaller particles that can bypass surgical masks.
“This high number of deaths in hospitals tells us that COVID-19 is indeed airborne as the Ontario Nurses’ Association (ONA) warned from the very beginning of the pandemic,” ONA president Vicki McKenna said Wednesday. “It didn’t have to be this way and the government was advised many times.”
Although studies have shown surgical masks do reduce transmission, they are otherwise not designed to prevent airborne spread; standard guidelines for controlling known airborne diseases, such as measles and tuberculosis, demand N95s or better, strict isolation protocols and a focus on ventilation.
Supporting the province against the nurses’ court challenge, 29 infection prevention and control professionals representing 24 Ontario hospital networks signed their names endorsing Directive 5 and stating their opinion that COVID is primarily spread by “droplet and contact” route, rather than airborne transmission.
Directive 5 saw its last major update in October, however, the basic reliance on “droplet and contact” protocols, with situational exceptions, have remained unchanged since spring 2020.
For Sharkawy, the death toll shows Ontario has “betrayed” the trust patients placed in hospital care amid the pandemic. He recalled, in particular, a female patient of his who had been at Toronto Western Hospital waiting on transfer to a different facility. The woman caught COVID-19 in a hospital outbreak before she could be transferred, and died following a “precipitous” illness, he said.
“It was such a bitter pill for me to swallow, knowing that we let that happen, that she probably would have been just fine had we had the right set up, the right design, the right level of tightness and seal around our patients,” he said.
Correction – Sept. 16, 2021: This article has been edited to correct that Rob Chorley contracted COVID-19 at Mississauga Hospital, not Oakville Trafalgar Memorial Hospital.
The article has also been updated to make clear the PHO report on COVID-19 outbreaks includes all cases linked to a declared hospital outbreak, but may not necessarily reflect the location where each person acquired the infection.