Canada’s two largest provinces have warned they may have to lock down parts of the economy again after a spike in Covid-19 cases.

Quebec, which has had more virus deaths than 40 US states, is an epicenter of the problem. The province has about 5,000 active cases, a 71% jump from the beginning of August, and is on the verge of closing bars and restaurants again in its two biggest cities, Montreal and Quebec City. Hospitalizations went up 26% in six days.

Ontario, the largest province with 14.7 million people, reported 700 new cases Monday, the most ever in a day, though it’s also testing far more people than it was in spring. A group of hospitals called on Premier Doug Ford’s government to revert to stricter “stage two” measures in Toronto and Ottawa, which would mean restricting or closing indoor businesses such as gyms, movie theaters and restaurants.

“It’s up to each of us. Together our collective actions will decide if we face a wave or a tsunami,” Ford said Monday at a news conference during which he pleaded for residents to follow rules and get the flu vaccine — but did not move the province back to stage two.

It’s a reversal of fortune for a country that avoided the summertime spike that hit the US As the pandemic got worse in Sun Belt states, a largely compliant Canadian population hunkered down and wore masks.

Provincial governments, which set the rules for most companies, allowed the vast majority of businesses to open up again, sometimes with capacity limits and new sanitation rules. In Toronto, the financial capital, many restrictions were lifted on July 31.

As Labor Day neared, virus cases started to rise again. They flared in British Columbia, praised for its early handling of the crisis. Nationally, active cases have more than doubled since Sept. 1, to 12,759. Almost 95% are in the four largest provinces, with the greatest problems in big cities.

Six months of restrictions left some Canadians just as restless as their counterparts in the rest of the world. Across the country, the spike in new cases is being driven by social gatherings among people in their 20s and 30s, fed up with social distancing and hoping to take advantage of the last weeks of warm weather.

“What we’ll tell people is: Stay home. We’re going to ask for a considerable social sacrifice,” Quebec Health Minister Christian Dube said in an interview on Radio Canada late Sunday. “There’s going to be difficult decisions for bars and restaurants” he added, as Quebec City and Montreal are about to be declared a “red zone,” the highest level in the province’s alert system.

The greater concern is that Covid-19’s toehold is becoming a foothold just as the country begins its rapid slide through autumn to winter, said Colin Furness, an infection control epidemiologist at the University of Toronto. This coronavirus survives and stays in the air longer in cold, dry weather, he said — people’s mucous membranes are less effective at filtering it out and infection rates are much higher indoors. Despite a run on fire pits and patio heaters, most policy makers are not expecting Canadians to dine outside in sub-zero temperatures.

Lower Mortality

One bright spot in the situation is the relatively low mortality rate in Canada. With the tragic exception of elder care facilities in Ontario and Quebec, where death rates soared early on, Canada’s fatality rate, per capita, is less than half that of the U.S. since the pandemic began — roughly 25 people per 100,000 population versus 63 in the U.S.

As treatments have improved, along with better protection for the elderly and, crucially, greater testing — and therefore identification — of cases in younger people, so have the mortality numbers.

But while a lower fatality rate is good news, it doesn’t protect hospitals from being overwhelmed by a surge in cases, especially during flu season. And there are significant health consequences with the virus, Furness said.

“If we focus just on the death rate, eventually everyone is going to say this is no big deal,” Furness said. “We should reframe our understanding of Covid as vascular disease that causes widespread brain damage in the population.”

For policy makers and politicians, protecting the hospitals, which already have enormous backlogs of delayed surgeries, and keeping the schools open are key. But the rising numbers threaten disruption on all fronts.

“If politicians do not have the political fortitude to reintroduce some restrictions, then our risk of sliding into something much worse — like the U.K. or Spain — that’s still on the table,” said Furness. Canada needs to implement rapid testing across the country, tighten definitions on “non-essential” travel and hold the line on 14-day quarantine periods for those who have been out of the country, he said.