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scatterplot of cities affected in USA in 1918

April 28, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

COVID-19 Update: There are no new cases of COVID-19 in our region today. There are a total of 59 cases of COVID-19 in the KFL&A region. There have been 38 cases in the Hasting-Prince Edward County area but a much higher incidence to the north and east in Leeds/Grenville/Lanark with 291 cases. There is 1 COVID-19 patient in KGH today on the Connell 3 COVID-19 ward. There are 7 designated COVID-19 outbreaks in regional long term care facilities but none in KFL&A (most affected facilities are in Leeds/Grenville/Lanark).

For those of us that are geographically challenged I have added a map.

area map

Testing for SARS-CoV-2, the virus that causes COVID-19 (good news/bad news): The good news is we are testing more people and the rate of positive tests in KFL&A remains low. 254 tests were performed in the past day; 7 were positive (all from Per Smith Falls). There were 70 visits to Memorial centre yesterday and all 70 people were tested for COVID-19.

Testing in Ontario as a whole continues to increase and we now do >12,500 tests/day (Figure below). The bad news is that the province has run out of nasopharyngeal swabs and have had to change testing product.

Tests performed vs positives

In the absence of nasopharyngeal swabs (which sample the very back of the throat) we have now switched to Cobas® swabs made by Roche. These swabs normally were used for sampling other parts of the body but have been shown to be effective in recovering virus. These probes sample form the middle turbinate area of the nose (halfway up the nose; not as far back as our old probes). It remains to be determined whether this change in swab will alter the performance of our test (we think not).

PPE: Our PPE supply chain is somewhat improved. We have a 3-4 week reserve at current rate use, up from 2-wewks. This reserve depends on using our pandemic supply.

Advice to people in the community re COVID-19 testing: People in the community can self-refer for assessment and possible and testing. We are still focusing on testing either symptomatic people (since the test for COVID-19 is likely not as specific in asymptomatic people) or people with confirmed COVID-19 contacts. In either circumstance please self-quarantine and seek out testing at Memorial Centre in Kingston, see instructions below.

Community instructions

Wonder why you are homeschooling your feral child and missing your favourite restaurants? Lessons from the pandemic of 1918 (click here): Are you starting to feel like all this staying home and school closures are too much? Do you wonder whether there is proof that physical distancing works? I offer the following compelling evidence that IT WORKS . There is powerful evidence on the benefit of “nonpharmaceutical” interventions from the last great pandemic. This story deals with lessons about the “nonpharmaceutical” intervention performed during the Spanish flu of 1918-19. This influenza pandemic infected 14,000,000 Americans, killing over 500,000. I was given this informative article by my wife, Dr Kathie Doliszny (who is an epidemiologist).

This historical experience demonstrates the benefits of a good political and social response to contagions, like COVID-19. These interventions are now referred to as physical or social distancing. The variable implementation of these policies in the USA in 1918 mirrors what we see today, with each state charting its own path. Since there is no cure or vaccine for COVID-19, much like the influenza that caused the 1918 pandemic, we can likely learn a lesson from history. 

History shows that cities that engaged in early and active physical distancing (#flattenthecurve #crush thecurve) reaped benefit and save lives, relative to their apathetic neighbours. There are two lessons: 1) the study, the pandemic took a lesser toll on cities that implemented these interventions earlier and for longer periods 2) the intervention only works when its being implemented-a second peak of influenza occurred when the physical distancing was relaxed. 

The paper is an interview with Dr. Markel who wrote a 2007 JAMA paper on the topic. Markel looked at city-to-city variation in mortality during the Spanish flu based on the timing, duration, and intensity of nonpharmaceutical interventions (defined as school closures; cancellation of public gatherings; and isolation and quarantine). As you can see (graph below): the longer cities waited to intervene with physical distancing, school closures etc. the higher their mortality rose. The cities that implemented nonpharmaceutical interventions earlier (New York City) were slower to reach peak mortality and had lower death rates .

scatterplot of areas affected in USA in 1918

For example, Philadelphia and Pittsburgh were affected early and were unprepared to respond, waiting over a week to intervene while the epidemic took hold. In contrast, New York City (NYC) intervened with a rigorous and mandatory system of nonpharmaceutical interventions before the death rate rose. As a result Philadelphia saw an excess death rate of 37/100,000 people vs no excess death rate in NYC. The Big Apple’s public health team shone bright! They responded the earliest to the epidemic, sustained their response for 10-weeks, rigidly enforced compulsory isolation and quarantine procedures, and staggered business hours. That’s why on the graphs above New York is the best in all regards. Pittsburgh is an interesting case. The state told them to introduce rigorous public health measures but the city leadership reversed the decision. Their results were the most lethal of the 43 cities in this study! Sobering, right? Fast forward to COVID-19 and 2020 in Kingston: our success locally reflects the great work of Public Health in KFL&S and the entire IPAC/incident command team at KHSC (as well as our awesome physicians, nurses , allied health care professionals, and a responsible populace). History is a good teacher and it appears we have landed on the right side of history (knock on wood)! That said, curves are flattening and relief from the joys of house arrest will be coming over the next few months!

Caring for the 99%: We continue to note increased need for urgent and semi-urgent care for numerous diseases at KHSC. Dr. Fitzpatrick, Chief of Staff, has solicited and received from all Departments a list of key conditions for which care cannot be deferred. This will guide us when we ramp up the provision of more elective care. Like all hospitals in Ontario, KHSC still does not have authorization from Ontario Health to return to provision of normal levels of care (i.e. we are not allowed to perform elective procedures and elective clinic visits). However, we continue to provide all necessary emergency care, urgent care and nondeferrable care (defined as conditions where harm would occur if care were delayed by 3 months).

alarm clock with smiley face

A daily reminder: Advice to our patients Our hospitals and clinics are safe places to receive care (in part because everyone including staff is screened prior to entry and in part because the local incidence of COVID-19 remains low). You should not delay accessing care that you or your doctor deem to be urgent. 

Canadian COVID-19 epidemiology: To date we have had 49,040 cases of COVID-19 in Canada, up ~2000 cases since Monday. There have been 209 additional deaths since Monday, resulting in a national total of 2769 deaths related to COVID-19. (click link for daily update). Here is a snapshot of COVID-19 in Canada today.

COVID-19 Canada Outbreak tracker

To see where Canada stands amongst nations in the COVID-19 pandemic, click here. To date there have been over 3 million cases and over 200,000 deaths globally. There is some evidence that the incidence is flattening.

graph of global cases and outcomes

Capacity in KGH: KGH continues to have good surge capacity (below). Note that we still have plenty of ventilators and beds available.

KGH Bed Capacity

How sweet it is: The doctors in the department of Medicine continue their tradition of thanking the nursing staff and other members of the team for their amazing, calm and professional care of our mutual patients during the pandemic. Dr Chris Smith, Michelle Matthews and Sharon Chapman join the team on Kidd 7 at KGH. Hope there is some left over for night shift! LOL.

Photo of Kidd 7 staff

Stay well!

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