COVID-19 IN CANADA

KEY UPDATES  Nationally, the number of cases reported daily continues to increase over the last two weeks. On average, 471 cases were reported daily from 22 to 28 July compared to 459 cases daily the week prior. o From 22 to 28 July 2020, a total of 3 297 cases were reported, representing a 3% increase from the previous week; however, the 50 deaths reported this week represented a 22% decrease compared to the seven days prior.  Severe illness at this point remains low and stable and cases in hospitals and ICUs across the country remain stable overall. There have been localised increases in hospitalized cases in some jurisdictions.  Of the cases reported to PHAC this week with information on age, 62% (1 546/2 490) of cases were under the age of 40; among the total number of cases that were hospitalized (including ICU admission), 16% (8/51) were aged 30 to 39.  A new section has been added to the report, which highlights hospitalized patients with COVID-19 who reported travel exposure, based on data from the Canadian Nosocomial Infection Surveillance Program (CNISP) and the Serious Outcomes Surveillance Network of the Canadian Immunization Research Network (CIRN-SOS).  Restrictions of non-essential travel into Canada, continue to aid in the control of imported cases, however, travel-related cases have risen incrementally each month and the proportion of cases with exposure associated with international travel has increased for the first time since March.  As provinces and health regions enter stages of re-opening, outbreaks within the last week continue to be primarily seen in food and drink establishments, mass gatherings and in faith communities.  The average number of people tested daily remains high over the last week with over 40 665 people tested per day. The weekly percent positivity has increased to 1.2% compared to 0.9% the week prior.

. Daily number of reported COVID-19 cases in Canada (and 7-day moving average), as of 28 July 2020 (N=114 994) a a Source: Provincial and Territorial MOH websites as of 28 July Note: The 7-day moving average is a trend indicator that captures the arithmetic mean of the daily reported deaths over the previous seven days. The moving average helps smooth out day-to-day variability in reporting, filtering out the "noise" of short-term fluctuations. Fluctuations can be attributed to retrospective data or provinces or territories reporting cases at a reduced frequency. The spike on 4 May is due to the fact that Quebec reported 1 317 cases diagnosed between 2 to 30 of April.
As of 28 July 2020, an increase in the weekly number of new cases was observed nationally (Table 1).  Quebec and Ontario continue to account for the majority of cases (63%) and Alberta, Ontario and Quebec account for the majority of deaths (84%) this week.  Increases in the weekly number of new cases per day was observed in Saskatchewan, Manitoba, Quebec, and Newfoundland and Labrador.  A decrease in the weekly number of new cases per day was observed in British Columbia, Alberta, Ontario, New Brunswick, Nova Scotia and Yukon.  Prince Edward Island reported no cases for this week. The Northwest Territories have not reported a new case since April 2020 and Nunavut remains to have no reported cases of COVID-19 since the beginning of this pandemic.
3 | P a g e P u b l i c H e a l t h A g e n c y o f C a n a d a Source: Provincial and Territorial MOH websites as of 28 July a The number of cases includes the total confirmed and probable cases; this includes 11 probable cases from Manitoba. These counts are based on publically available information from the provincial/territorial ministry of health websites. b The percentage is calculated based on the difference in the total number of cases in the past 7 days over the past 7 days prior. Note that for provinces/territories with low case counts, an increase or decrease of only a few cases leads to a large percentage change.
c Information as of 27 July 2020. d Includes 13 cases identified in repatriated travellers (Grand Princess Cruise ship travellers) who were under quarantine in Trenton in March 2020.
4 | P a g e P u b l i c H e a l t h A g e n c y o f C a n a d a Figure 2 and Table 2 present the age-standardized rate by province or territory for the week of 22 to 28 July 2020.  Saskatchewan reported the highest cumulative age-standardized incidence rate in Canada, with 19.9 cases per 100 000 population (see table A2 in annex for cumulative counts).
Age-standardized rates take into account the differences in age structure within Canada to allow for a representative picture of the outbreak.
Figure 2. COVID-19 age-standardized incidence rate per 100 000 population a by province or territory for week 22 to 28 July 2020

COVID-19 IN CANADA
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o The highest incidence rate in age is in both males and females ages 20-29 years (13.9 and 13.4 cases per 100 000 population respectively) followed by males and females ages 30-39 years (8.7 and 7.2 cases per 100 000 population respectively) ( Table 4).  Of the cases reported to PHAC this week, 62% of cases were under the age of 40; among the total number of cases that were hospitalized (including ICU admission), 16% (n=8/51) were ages 30 to 39. Possible explanations for the increase in proportion of cases in younger age groups, include: o Younger individuals increasing in-person physical connections, because of return to either workplaces or associated summer activities/holidays, reduced adherence to physical distancing measures, or isolation fatigue. o Although young adults are at lower risk of severe outcomes than older adults, risk is not zero in this group and, moreover, infected individuals who do not experience severe outcomes can transmit the infection to people at higher risk.

COVID-19 IN CANADA
7 | P a g e P u b l i c H e a l t h A g e n c y o f C a n a d a Figure 3 present cases by illness onset, stratified by sex and adjusted for population at the national level.  As of 6 July, those ages 20 to 39 remain consistently higher when compared to all other age categories.  As more case report forms are submitted, the proportion of cases relative to other age categories is subject to change.
Figure 3. Daily cases by age and sex, population adjusted from 1 June to 28 July 2020 Note: The shaded area represents a period of time (lag time) where it is expected that cases have occurred but have not yet been reported nationally. If date of illness onset was not available, the earliest of the following dates was used as an estimate in the following order: Specimen Collection Date and Laboratory Testing Date.
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OUTCOMES AND SEVERITY
From 22 to 28 July 2020, 50 deaths were reported in Canada.

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This represents a 22% decrease compared to the previous week (15 to 21 July), and a continuation of a downward trend since early May ( Figure 4).

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Contrary to the observed increase in weekly cases, there has been an observed decrease in weekly reported deaths.
o Factors may include reported lag time, laboratory tests capturing milder and younger cases less at risk of adverse outcomes, improved treatment options, or greater knowledge and training for front-line workers.
During the same period, jurisdictions submitted individual level information for two deaths to PHAC (Table 5). Both cases were over the age of 70, with a median age of 77.5 years, and half of the cases were male. Note: The 7-day moving average is a trend indicator that captures the arithmetic mean of the daily reported deaths over the previous seven days. The moving average helps smooth out day-to-day variability in reporting, filtering out the "noise" of short-term fluctuations. Fluctuations can be attributed to retrospective data or provinces or territories reporting cases at a reduced frequency.
From 22 to 28 July 2020, detailed case information on hospitalization status based on PHAC report date were reported for 1 311 cases. Among these cases:  51 (4%) were hospitalized, of whom: o 10 (20%) were admitted to ICU, and o 2 (4%) required mechanical ventilation.
Detailed case information were reported for 114 029 cases in total; hospitalization status information was available for 77 384 (68%) of cases since the start of the outbreak, where:  11 018 (14%) were hospitalized, of whom: o 2 237 (20%) were admitted to ICU, and o 464 (5%) required mechanical ventilation.

COVID-19 IN CANADA
9 | P a g e P u b l i c H e a l t h A g e n c y o f C a n a d a Based on detailed case information provided to PHAC, the overall cumulative hospitalization rate (including ICU admissions) was 29 cases per 100 000 population, with the highest rates observed in those 80 years and older (224 cases per 100 000 population). There continues to be a downward trend in the number of cases hospitalized and in ICU, across the country ( Figure 5).

COVID-19 IN CANADA
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SURVEILLANCE FOR COVID-19 AMONG PATIENTS HOSPITALIZED IN CANADIAN ACUTE-CARE HOSPITALS
Laboratory-confirmed COVID-19-associated hospitalizations in Canada are monitored through two sentinel hospital-based systems: 1. Canadian Nosocomial Infection Surveillance Program (CNISP). 2. Serious Outcomes Surveillance Network of the Canadian Immunization Research Network (CIRN-SOS).
As of 22 June 2020, case-level data is available on 1 030 of these patients in 31 hospitals across 8 provinces. CNISP also collects weekly aggregate data for all age groups (n=2 594) from 148 hospitals across all 10 provinces. Both figures presented below are based on the weekly data received as of 18 July 2020.
As of 23 July 2020, CIRN-SOS has collected information on 647 adult patients (≥16 years) hospitalized with COVID-19 across 8 hospital sites in Ontario, Quebec, and Nova Scotia.

Key Findings:
 CNISP weekly estimates of laboratory-confirmed COVID-19 admissions per 1 000 hospital admissions peaked at 15.7, in the week of 19 April 2020. The estimates have decreased and remained below 5.0 since the week of 31 May 2020 a (see Figure 6).

Figure 6. National rates in participating CNISP hospitals with 95% confidence interval
Note: Only includes data from the 142 hospitals that have participated in all weeks of aggregate data collection (n=2 544) and is estimated using 2019 annual or quarterly data.
11 | P a g e P u b l i c H e a l t h A g e n c y o f C a n a d a  Median time from symptom onset to hospital admission was 5 days among CIRN-SOS patients (n=526 Information on exposure is available for 750 cases with illness onset in the week of 22 to 28 July. Of these:  9 cases (1%) reported having travelled outside of Canada during the exposure period;  197 cases (26%) were due to exposure in Canada to a known COVID-19 case;  398 cases (53%) were due to exposure in Canada to an unknown source;  1 case (<1%) was due to exposure to a traveller; and  145 cases (19%) have information on exposure pending.
Jurisdictions update exposure status on an ongoing basis as case investigations are completed, which may result in information currently pending changing exposure category in the future. Conversely, some cases which have information pending from early in the outbreak may be lost to follow-up, and exposure category may not be identified (Figure 8).
Of the 113 525 cases with information on exposure provided:  4 687 cases (4%) reported having travelled outside of Canada during the exposure period;  62 171 cases (55%) reported exposure in Canada to a known COVID-19 case;  925 cases (<1%) reported exposure to someone who had travelled;  39 721 cases (35%) reported exposure in Canada to an unknown source; and  6 021 cases (5%) have information on exposure pending. P u b l i c H e a l t h A g e n c y o f C a n a d a Cumulatively, information on exposure with illness onset indicates that 54% of cases report exposure to a known COVID-19 case.  From 22 to 28 July, more cases reported exposure to COVID-19 from an unknown source (53%) than a known source (26%); however, it is important to note the inherent delays in these indicators. P u b l i c H e a l t h A g e n c y o f C a n a d a  (n=109); however travel has increased slightly to 2.5% in July (n=110) ( Table 6).  Since 1 May, the most commonly reported countries of travel included the United States, Mexico, Pakistan, India and Guatemala. From 22 to 28 July, nine cases of COVID-19 in Canada associated with international travel were reported to PHAC.  Of the nine cases, travel was reported to Mexico (n=2), Guatemala (n=2), the United Kingdom (n=1), Portugal (n=1), France (n=1) and Algeria (n=1). One was unspecified.  The majority of international travel-related cases occurred prior to the implementation of travel restrictions, with the highest amount reported in March and the majority of domestic cases with exposure to an international traveller were reported in April (Figure 9).  Since the beginning of the outbreak, the United States and Mexico continue to make up the largest proportion of cases with international travel exposure in Canada.  Restrictions of non-essential travel into Canada, continue to aid in the control of imported cases, however, the proportion of cases with exposure associated with international travel is the highest since March. P u b l i c H e a l t h A g e n c y o f C a n a d a Figure 9. Number of travel-related COVID-19 cases in Canada, by illness onset date (n= 5 642)* *Includes all cases reported to PHAC with links to international travel (i.e. reported travel or contact with international traveller). **If date of illness onset was not available the earliest of the following dates was used as an estimate in the following order: specimen collection date and laboratory testing date.
Date of illness onset**

COVID-19 IN CANADA
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INTERNATIONAL
 As of 28 July, globally, there are over 16.5 million cases of COVID-19 with over 650 000 reported deaths.
Since 15 July, there has been over 200 000 cases reported globally each day.  The global single-day record occurred on 24 July with over 284 000 cases reported.  The region of the Americas continues to account for the majority of cases reported (54%), with the United States (26%) and Brazil (15%) reporting the largest proportion of cases ( Figure 10).  The following five countries account for the largest proportion of cases globally: o South Africa (3%)  Canada's daily cases account for less than 0.7% of all cases reported globally. The 7-day moving average of new daily COVID-19 cases in Canada compared to other countries can be seen in Figure 11. France, Germany, and Japan are seeing increases in case counts. Japan has now surpassed Italy in population-adjusted daily reported cases and Sweden continues to decline, approaching Canadian population-adjusted daily case counts. P u b l i c H e a l t h A g e n c y o f C a n a d a Figure 11. Daily new cases of COVID-19 in Canada compared to other countries as of 28 July 2020 (7-day moving average, population adjusted) Up-to-date country-specific risk levels may be found on travel health notices. For more information on COVID-19 internationally, please refer to the World Health Organizations' COVID-19 Situation Report. Further information on geographical distribution of COVID-19 cases, can be found on the global map. P u b l i c H e a l t h A g e n c y o f C a n a d a OUTBREAKS  Outbreaks have been important contributors to the spread of COVID-19 in Canada and point to vulnerabilities in closed and crowded settings. Table 7 identifies common locations of outbreaks identified, as well as the number of cases and deaths associated with each.  Outbreaks in congregate living, workplace, and agricultural work settings have been detected, namely among long-term care settings, meat processing plants, hospitals, and among farm workers. o Long term care facilities and retirement residences account for the majority of outbreaks.  With the gradual reopening of society and activities resuming, outbreaks are becoming linked to social gatherings, particularly in closed settings with close contacts (e.g., retail, personal service, food, and bar settings)  Outbreaks that have occurred in the last week are primarily seen in food and drink establishments, mass gatherings and in faith communities. Three food and drink establishments were grouped into one cluster f Child and youth care includes daycare centers and day camps. Note:The following categories have been included for this week's report and includes both current and retrospective data.
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FLUWATCHERS
FluWatchers is an online health surveillance system that relies on volunteer reports to track spread of flulike illness (ILI) across Canada. Mild COVID-19 illness presents with symptoms similar to ILI; therefore, FluWatchers is shifting focus to track COVID-19 symptoms over the spring and summer months.
In the week of 19 to 25 July, 2020, 9 657 participants reported into the FluWatchers program. A total of 10 participants (0.1%) reported cough and fever (Figure 12). The participants reporting cough and fever were not restricted to a single jurisdiction. As FluWatchers does not normally collect data during the summer months, this cannot be compared to historical Canadian data. Similar participatory ILI surveillance programs in other countries are also reporting historically low levels. These low levels may be due to a combination of factors, including physical distancing. Among the 10 participants reporting cough and fever:  6 (60%) sought medical attention;  4 (40%) were tested -No tests were positive for COVID-19 Overall, 3 801 950 people have been tested for COVID-19 in Canada as of 26 July 2020, and the cumulative percent positive to date is 2.8% (Table 8).
From 20 to 26 July 2020, 281 408 persons were tested for COVID-19. The weekly average percent positivity is 1.2%. Nationally, Canada's rate of testing decreased (-6.8%) from the week before.  British Columbia (+2.5%), Manitoba (+200%), Alberta (+18%), Ontario (+2.3%) and Saskatchewan had increases in the number of persons tested. o Saskatchewan's percent positivity increased from 1.4% to 3.0% o Quebec's percent positivity increased from 1.4% to 3.6% Table 8. Summary of COVID-19 testing reported in Canada, by province or territory, between 20 to 26 July 2020 (N=3 801 950) Province/Territory Total number of people tested a Difference from last report P u b l i c H e a l t h A g e n c y o f C a n a d a Figure 13. Onset date and lab collection date for cases reported to PHAC as of July 13 Note: Onset to specimen collection intervals of >15 days are deemed outliers, and not included in this figure.
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MODELLING
Estimates of transmission rates in Canada: Effective reproductive rate (Rt) Rt is the time variable reproduction rate, representing the average number of new infected people for each infected person. If Rt is less than 1 at a particular time (t), then the average number of people infected by one infected person is less than one, so the epidemic is being brought under control. If Rt is greater than 1, the average number of people infected by one infected person is greater than one, and the epidemic is growing. A value of Rt above 1 indicates that there is active community transmission, meaning that the disease will continue to spread into the population. The higher the Rt value, the faster the disease is spreading, which leads to an increase in incidence of new cases.
However, as the epidemic continues, the Rt may not capture the current state of the epidemic with low case burden and the value must be interpreted based on the current landscape. The Rt can easily fluctuate when case numbers are low. It is also an average Rt for a population and does not point to local outbreaks driving case counts. Since the method used to calculate Rt is highly sensitive to the number of new cases, community outbreaks within specific provinces and territories will cause the estimated Rt value in that respective region to be higher, which may not always accurately depict overall transmission in the province/territory as a whole.   Models cannot predict the course of the COVID-19 pandemic, but can help us understand all possible scenarios, support decisions on public health measures and help the health care sector plan for these scenarios.
Forecasting models use data to estimate how many new cases can be expected in the coming week. Figure  15 below shows the projected number of cases and deaths in Canada, with a 95% prediction interval calculated using available data up until 27 July 2020.  According to forecasting, 119 480 to 124 630 cumulative reported cases and 8 900 to 9 035 cumulative numbers of deaths are expected by 11 August.  The increased number of daily reported cases is predicted to be 450 cases to 500 cases per day during the period from 27 July to 11 August. The predicted cumulative deaths suggest a stable small numbers of daily deaths with an average of four deaths per day, during the period of 27 July to 11 August.  The black dots represent data (cumulative cases and for cumulative deaths) prior to 22 July and the dashed lines show the predicted trajectories beyond 22 July. It is important to communicate the underlying uncertainties around modelling. The red and green lines represent the upper and lower limits with 95% confidence. If the forecasts perform well, observed cases should fall between the red and green lines. Figure 15. Projected numbers to 11 August 2020 and 95% prediction intervals based on data as reported by 27 July 2020 For more information, please visit: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/covid-19-using-data-modelling-informpublic-health-action.html

COVID-19 IN CANADA
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TECHNICAL NOTES
The data in the report are based on information from various sources described below. The information presented for case-based analyses is that available as of 28 July at 8 p.m. EDT. The information presented for trend analyses is that available as of 28 July at 8 p.m. EDT. The information presented for laboratory analyses is that available as of 26 July at 8 p.m. EDT.

Provincial and territorial case counts
Provincial and territorial (P/T) information on case counts, recoveries, and deaths associated with COVID-19 are collected from publicly available P/T websites.
 National case definitions are provided by PHAC for the purpose of standardized case classification and reporting. PHAC's national case definitions can be found here: https://www.canada.ca/en/publichealth/services/diseases/2019-novel-coronavirus-infection/health-professionals/national-casedefinition.html  Only cases and deaths meeting P/T's definition for case classification are reported. For details on case definitions, please consult each P/T ministry of health website.

Laboratory information
Laboratory data on number of people tested per P/T are received from the National Microbiology Laboratory.  Laboratory testing numbers may be an underestimate due to reporting delays and may not include additional sentinel surveillance or other testing performed. They are subject to changes as updates are received.  Some provinces may report the number of tests conducted, and not the number of people tested. In this case, a formula is used to estimate the number of unique people tested.

Epidemiological data received by PHAC
Some of the epidemiological data for this report are based on detailed case information received by PHAC from P/Ts. This information is housed in the PHAC COVID-19 database. Case counts and level of detail in case information submitted to PHAC varies by P/T due to:  Possible reporting delay between time of case notification to the P/T public health authority and when detailed information is sent/received by PHAC.  Preliminary data may be limited and data are not complete for all variables.  Data on cases are updated on an ongoing basic after received by PHAC and are subject to change.  Variation in approaches to testing and testing criteria over time within and between P/Ts.  The lag time from illness onset to PHAC report date is approximately two weeks and data within this period is subject to change.  Missing data for sex, age, hospitalized, ICU admissions, and deceased were not included in calculations. Provinces and territories may define gender differently and some may be referring to biological sex.