April 8, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
Word of the day: Quarantine: In the 14th century ships arriving in Venice from infected ports were required to sit in the harbour for 40 days before landing. This practice is the origin of the word quarantine, which is derived from the Italian, quaranta giorni, meaning “40 days”. Fortunately our COVID-19 quarantines are only 14 days!
Miracle of the True Cross at the Bridge of S. Lorenzo Gentile Bellini (b:1429, Venice)
COVID-19 Update: There are 53 people with COVID-19 infection today in our region, with no new cases in the past 48 hours. The peak in COVID-19 infections for Ontario will likely occur next week. The highest prevalence of infection in Ontario is in Toronto, with a second peak in Ottawa. Two patients with COVID-19 infection are currently admitted to KGH, on Medicine’s COVID-19 unit (awaiting discharge) and 2 more are in the ICU. Some additional good news from Providence Care Hospital, where there were quarantines on two units related to infected staff members. The quarantines are over and there was no COVID-19 transmission to patients or co-workers. This is a reminder that while COVID-19 can be easily transmitted with proper precautions, transmission can also be avoided.
The low incidence of COVID-19 in our region and the persistent international shortage of PPE in combination support the safety and wisdom of the hospital’s current decision not to deploy universal PPE throughout the hospital. We are not currently in the situation Toronto and Ottawa, are experiencing, where because of much higher case-loads they are more broadly deploying PPE in their hospitals. A final word on the local outbreak (repeated from yesterday): Please fight the urge to socialize on this Easter weekend, our low local prevalence is a function of our active programs of physical distancing; don’t give the virus a break…stay home!
Testing for COVID-19: At KHSC we can do 320 COVID-19 diagnostic tests per day (see yesterday’s note) and will be able to do 500 tests/day by the end of April. Testing for the virus that causes COVID-19 infections, SAR-COV-2, is largely reserved for people with an acute respiratory (lung) infection. As the epidemic has evolved, we no longer require foreign travel to justify testing. Testing for staff is done at the Hotel Dieu site and, as discussed in prior updates, the public can be screened and potentially tested at the Memorial centre site. We (KGH and KFL&A Public Health) don’t currently have capacity to test asymptomatic people and, even if we did, the negative predictive value of the PCR test is not well established. In other words, it’s hard to know what a negative test means if you don’t have symptoms (outside of a population surveillance study). In other words, this is not a screening test.
What is the future of the COVID-19 pandemic? lessons may (or may not) be learned from the world’s last viral pandemic
In his article The Origin and Virulence of the 1918 “Spanish” Influenza Virus, Taubenberger offers some lessons from the last pandemic (the Spanish flu of 1918). Some are saying this may give us some clues as to how and when the current epidemic may end. However, before you read this paragraph, remember the words of Yogi Berra, famous New York Yankees ball player and source of quirky aphorisms, predicting the future is tough! Viral pandemics are rare and each is unique. People worry that we will have multiple waves of COVID-19, lasting over several years. In my opinion, it’s too early to tell (but then again, I’m a cardiologist!). However, if there are historical lessons to learn they come from the history of another virus, influenza. Influenza has caused pandemics but now tends to cause seasonal outbreaks. Usually the waves of infection in a viral pandemic are spread over several years. The occurrence, timing and severity of a second wave of infection, after the initial epidemic resolves, is hard to predict. The last global pandemic to date was caused by a strain of influenza in 1918. In that case, there were 3 waves of infection, coming unusually close together in time. I mention this only because I hear lots of analogies between Spanish flu and COVID-19 being proposed. The fact is, we don’t yet know what will happen and will be relying on lessons from global epidemiology and particularly from China to figure this out in coming months. My advice is that we get through the next few months before worrying about future waves, which may or may not materialize. Nonetheless here is what happened with the last two influenza pandemics, per Jeffrey Taubenberger.
Jeffrey Taubenberger of on the Spanish Flu, 1918 (and a lesser pandemic in the 1890s) “ Even in pandemic influenza, while the normal late winter seasonality may be violated, the successive occurrence of distinct waves within a year is unusual. The 1890 pandemic began in the late spring of 1889 and took several months to spread throughout the world, peaking in northern Europe and the United States in late 1889 or early 1890. The second wave peaked in spring 1891 (more than a year after the first wave) and the third wave in early 1892. As in 1918, subsequent waves seemed to produce more severe illness, so that the peak mortality was reached in the third wave of the pandemic. The three waves, however, were spread over more than three years, in contrast with less than one year in 1918. It is unclear what gave the 1918 virus this unusual ability to generate repeated waves of illness. Perhaps the surface proteins of the virus drifted more rapidly than other influenza virus strains, or perhaps the virus had an unusually effective mechanism for evading the human immune system. It has been estimated that the influenza epidemic of 1918 killed 675,000 Americans, including 43,000 servicemen mobilized for World War I. The impact was so profound as to depress average life expectancy in the U.S. by more than ten years… (and may have shortened world war I).
A Shout out to Geriatrics and Providence Care Hospital (PCH)
Although I talk a lot about the great work at KGH, we are not alone in preparing for COVID-19. Our colleagues at PCH, including but not limited to our Departmental members in Geriatrics and Palliative Care, have proactively dealt with the COVID-19 epidemic and have been superb partners in relocating and managing our mutual patients. Our Chair of Geriatrics, Dr. John Puxty, is a regular member of PCH’s Incident Command and the Planning Group. It’s great to see medical administration closely aligned with physicians in decision making at PCH. As at KGH, the pandemic has enhanced the relationships between physicians and hospital administration.
PCH has moved mountains to create an additional 175 bed capacity. Some 19 beds are being put in regular clinic space and the ECT Recovery room. These rooms, adjacent to the current Geriatric inpatient unit, have oxygen and lifts so are suitable for the types of patients that are anticipated. Let me offer my thanks to the Division of Geriatrics who unanimously supported staffing this expansion.
To avoid exposing patients to unnecessary contact with hospitals, the Division of Geriatrics has a robust triage and screening process in place and has also launched its e-consults and tele-consults program as part of the DOM suite of e-offerings. Video consults will follow soon! Geriatric’s educational activity is continuing with active use of both ZOOM and in person (with social distancing). Drs. Michelle Gibson and Leah Nemiroff have shown great leadership in this regard. Dr. Puxty asked me to thank groups like Information Technology and Human Resources at PCH, who have been responsive and made these things happen quickly.
We’re Still Here: Team DOM is working to support you
I am so proud of my DOM administrative team. They are working longer hours than ever to support our many faculty, staff and trainees. The DOM is the largest Department at Queen’s and this remarkable crew manages to support rounds, blogs, implementation of video visits, hiring of new faculty, paying faculty and staff, all the while maintaining their humor. If you need to see a smiling face or need help in a time of crisis or stress, stop by the DOM and talk to Anita Ng and her team. We are here to serve!
Thinking of your family: Health care workers, including clinical secretaries, trainees and faculty may worry about bringing infections home to their loved ones. While worry is understandable let me offer some perspective and then some tips of how to both be safe and feel calm and secure. Let’s review some information. First, there is little COVID-19 in our region at present, as discussed above. Second we have extensive measures in place to protect health care workers from COVID-19 infections in the work place. For example, we screen all people (including staff) entering our buildings to avoid importing the disease. When workers are sick, they are told to stay home. In areas of the hospital where patients may show up unannounced from the community, like the Emergency Department, all staff wear PPE. We have also limited access of visitors to KHSC to limit accidental spread of the disease from the community to healthcare workers. When people are working with COVID-19 patients they have full PPE. Finally, we have cohorted COVID-19 cases in very specific areas (Connell 3, ICU and part of the Emergency Department), so that most health care workers will not encounter a COVID-19 positive patient. You might worry that you could be asymptomatic and still infect your family. True that is possible, although it is not much more likely than that this would occur in the community. As discussed yesterday, asymptomatic people are, in general, not very infectious. The facts to date are that in China (and in Canada) most infections are acquired in the community or in nursing homes and the risk of transmission is greatest when the person that has COVID-19 lives in your house. Infections being acquired from a health care worker can occur to be sure; but we are not major disease vectors! So in general, I see no reason to move out of one’s home simply because you are a health care worker (unless you have a COVID-19 infection and can’t be quarantined at home).
Nonetheless it is natural to worry and media stories of disrupted families tug on our heart strings. However, before considering leaving home I would add to the argument that the risk of bringing an infection home is low, the fact that this is a marathon and things won’t likely normalize for months. So, while you could move in to one of the discounted hotels that are available to KHSC staff, months away from family would be an emotional and psychological stressor that is hard to justify based on the reality of our low (negligible) local risk of hospital-worker transmitted COVID-19. True, this could change; but if and when that occurs we will be sure to share that intel.
This poster has great tips for health care workers and their families to allow them to both be safe and feel safe. Please share it with your families.
Here is a look at the progression of the COVID-19 epidemic in Canada since January 25th.
Cases in Canada (white and Ontario (3rd curve down, orange)
As you can see Canada continues to experience a progressive rise in cases and the curve has not yet flattened nationally (although it has in British Columbia-right panel). The curve is also flat in Kingston!
There are currently 19,194 cases and 427 deaths related to COVID-19 in Canada.
See KGH capacity on today’s graphic indicator below. There is a paradox that as we await to see how the epidemic plays out locally, the hospital is at an all-time low census. This has been done intentionally so that we have capacity for abrupt increases in COVID-19 admission. This means some wards have staff capacity. We are concerned attentive to the job security of our staff (nurses and others). Kudos to the leadership of the Medicine program, who have been creative and worked hard to retain all staff. When there is limited patient care service need available on one’s own home unit, staff are offered training, vacation time or redeployment to other services to cover vacancies. We are working hard to maintain our highly valued partners in nursing and administration.
Clarification on PPE recycling: We have received a new supply of PPE, including both new masks and “expired” masks. These products don’t degrade and even so called “expired” masks are safe for use (and testing will be done to prove this). We continue to recycle and re-sterilize noncontaminated PPE. Occupational Health is ensuring that the recycling is safe and effective, since staff safety is priority 1. We are testing products after recycling to make sure they still work. There are two bins at each recycling point (they look the same with yellow biohazard bag) One is for masks (surgical and N-95) and the other is for eye protection and face shields. Remember, When you remove the masks for recycling, don’t pull them off, remove them as you put them on, carefully! Soiled, damaged or wet masks, including those with makeup on, cannot be recycled. Do not put garbage or gloves etc. in these bins. Please help us by conserving and recycling PPE!