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updated screening questions

December 10, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

headlines

 

1) KHSC has a new inpatient case, 2 staff that have tested positive and new screening questions related to red zone travel: ACOVID-19 patient was admitted to the Medicine service at KHSC and 2 staff have tested positive. With the rise in community incidence, KHSC is implementing new screening questions about travel to and visitors from Red Zones or outside Canada.

2) COVID-19 volumes have dramatically increased in KFL&A related to a super spreader event at a local church (click here) and to student house parties around Queen’s University (click here(see update from KFL& A Public Health):

3) Vaccine side effects are relatively rare and often overstated (a reminder that the human body does react with local pain, fever and fatigue when immunity is stimulated) (click here)

4) Ontario has had 134,783 cases since the pandemic with 1983 new cases since yesterday, a total of 16,034 active cases and 829 people in hospital (click here): 

5 ) Canada’s second wave of COVID-19: We have had 437,310 total cases to date, with 3121 people currently in hospital (19.4% in ICUs) (click here)

6) The COVID-19 global pandemic has seen ~1.58 million deaths and 69.2 million cases, up ~ 2 million since Monday (click here): 

7) Good news stories:

  • Praise for KFL&A public health from Ontario’s auditor general
  • Bucks for Baskets-The DOM raises funds for the Partners in Mission Foodbank

Regular reminders and updates:

  • KHSC bed capacity (not updated at time of note) 
  • Use the Mobile Screening Tool to expedite clinic visits 
  • KHSC visitor policy
  • COVID-19 testing at Beechgrove Community Assessment Center: (click here): 
  • Increased outbreaks and deaths in Long Term Care facilities (LTC)
  • COVID-19 in toddlers and young children: (click here). 

1) KHSC has a new inpatient case, 2 staff that have tested positive and new screening questions related to red zone travel: A patient with COVID-19 was admitted to KGH on Medicine’s COVID-19 ward, Connell 3. Two KHSC staff have tested positive for COVID-19. 

COVID-19 infections are almost always acquired in the community and brought into hospitals (not vice versa)! Thus, with the rise in community incidence it requires us to be more vigilant about keeping COVID-19 out of the hospital. Consequently, KHSC is implementing new screening questions about travel to and visitors from Red Zones, like Toronto, Ottawa, Windsor and Peel. This question also applies to visitors from outside Canada. It is noteworthy that this restriction only applies to the person trying to enter KHSC and they would not fail screening if the person who travelled to the red zone was their child or partner (see table below).

new covid screening questionstable listing criteria for travel

New KHSC screening question will be implemented tomorrow

If a visitor answers positively (i.e. they have been to a red zone or been visited by a red zone resident they will not be allowed to enter KHSC facilities.

For healthcare workers that fail this screening question (assuming they are asymptomatic): These staff will be reviewed by occupational health and may be permitted to work under our workplace isolation policy. 

2) COVID-19 volumes have dramatically increased in KFL&A related to a super spreader event at a local church (click here) and to student house parties around Queen’s University (click here(see update from KFL& A Public Health):

There have been 28 new cases in the region since my note on Monday. There are now 67 active cases in the region, up from 16 roughly a week ago. There are also 41active cases in Hasting Prince Edward and 40 cases in Lanark Leeds Grenville. There are 14 regional COVID-19 outbreaks (workplaces, retirement homes and nursing homes). Unfortunately, the rise in cases in KFL&A is due to a 1-2 super spreading events (currently being contact traced). These new cases include people in all age groups, with 3 cases in people over age 80 years. As mentioned on Monday, infections in the elderly usually foreshadows hospital admissions and we now have patient hospitalized at KGH. This week has seen the greatest number of new cases since the pandemic began, reminding us we need to increase our vigilance as we await our chance to get vaccinated. 

3 graphs pie, bar and line showing covid data for KFL&A

The pre-Christmas surge in cases in KFL&A relates to failures to follow public health practices and conversely can only be resolved by recommitting to following good public health practices

As you can see from the table below the outbreaks in December are mostly “Other”. To be blunt: in most cases “other” means groups of people who have not followed public health guidelines and have assembled in large groups, often without masks. Don’t be an “other”. The cost of failing to wear masks indoors, maintain physical distancing, self-isolate if sick and wash hands is the recent spike in local disease which puts southeastern Ontario at risk. I would encourage people to think of following these rules and accepting the vaccine when offered as civic responsibilities that should supersede personal fears and biases. 

table outlining current covid data in KFL&A

The total number of cases in KFL&A since the pandemic began is now 336 with 148 active case active cases in southeastern Ontario, also the highest number since the pandemic began. There are 2 people hospitalized in southeastern Ontario 1 at KGH and 1 in Lennox, Leeds Greenville (see update from KFL& A Public Health). 

There are a couple of recent events that deserve comment as they constitute egregious violations of public health guidance.

Queen's logopicture of third day worship centre entrance

Two Queen’s students who attended house parties have tested positive (click here). This is to say the least unfortunate behaviour. We are well past the point where house parties can be forgiven as youthful indiscretion. The university has reported 10 cases of the virus since Nov. 30, all of them off campus. The most recent cases (and the house parties) occurred on Dec 4th and 5th. The Queen’s motto is Sapientia et Doctrina Stabilitas, from the Latin as "Wisdom and knowledge shall be the stability of thy times. "Student’s should apply this “wisdom and knowledge” to guide their behaviours during the pandemic for the safety of the community that is supporting them in their goals of obtaining a higher education.

screen shot of news article re house parties and picture of house rooftops

The other event worthy of mention involves the 3rd Day Church, which has had a super-spreader event with 24 cases identified (as of Dec 8th) (click here). There were 9 initial cases and then a further 15 cases who were close contacts. This church has now moved its services on-line. However, they shared an egregious Facebook posting soliciting people to come from Toronto (in lockdown) to attend the Third Day Worship Centre in Kingston (a yellow zone).

screenshot of text telling people to come to Kingston church from toronto

To be clear, the Third Day Worship Centre didn’t create the post on social media. It was created by T.J. Malcangi-Salvation Now, a self-proclaimed Evangelist who “began preaching the Gospel of Jesus Christ full time in January 2016,” according to his website. However, the Third Day Worship Centre did share Malcangi’s post on their own social media feed, giving this dangerous idea oxygen! The post was removed over the weekend (click here). If the Third Day Worship Centre sounds familiar, it has been in the news of late, related to controversial statements from its pastor, including homophobic, Islamophobic statements and inaccurate and misleading statements about the COVID-19 pandemic (per reporting in the WHIG Standard (click here).

new article  stating mayor Patterson distances himself from church with a photo of third day worship centre entrance

Bottom line: Neither youth nor religion will protect you and your loved ones from COVID-19!

Please: 

  • Be extra vigilant because the case load is now high in our region! 
  • Continue to wash hands, mask, and maintain physical distancing
  • Do not assemble in large groups-this is what drives super-spreader events! 
  • Avoid travel to high prevalence areas like Toronto, Peel and Ottawa. 

3) Vaccine side effects: relatively rare and often overstated (a reminder that the human body does react with local pain, fever and fatigue when immunity is stimulated) (click here)

As you have likely heard two allergic reactions reported by U.K. health-care workers prompted British regulators to advise people with a history of “significant” allergic reactions to pass on vaccination. I suspect this is a political rather than a medical decision. Most people in the clinical trials, a diverse group of carefully monitored people of all ages and races, had no adverse effects whatsoever. Dr. Moncef Slaoui, the leader of the US Warp speed vaccine effort acknowledges that 10-15% of vaccinated people had mild adverse effects and “reported redness and pain at the injection site as well as fever, chills, muscle aches and headaches, he said, adding most people have no noticeable side effects.” (click here). However, these minor reactions were transient, lasting <1 day. This is largely a sign one’s body’s immune system is being activated-which is the whole point of a vaccine!

Serious side effects were not more common with the vaccine than in the placebo group. Remember, life goes on even during a clinical trial. People develop diseases as they normally would. Pfizer Canada’s president Cole Pinnow said the four occurrences of facial paralysis among close to 22,000 subjects in U.S. clinical trials who received the Pfizer-BioNTech COVID-19 vaccine represented a frequency not above what is expected in the general population (click here). I agree with her. Putting adverse outcomes into context is always the struggle when testing a new drug or vaccine. Both the vaccine and placebo group will have a background (normal) rate of heart attacks, strokes, cancer and yes, Bell’s palsy. To determine whether these adverse events would have occurred even had the person not been in the clinical trial we have a placebo group. Adverse events are only “real” and related to the vaccine if they are more common in the vaccine group than in the placebo group. Bell’s palsy is a form of one-sided, facial paralysis which is usually reversible. It has a normal annual incidence of 15–30 cases per 100,000 population. Thus it would not be unexpected to see 4 cases in a clinical trial of 43,661 people, studied over several months. There was no statistically significant increase in this event in the vaccine group.

scientist in a lab with machines

Of course the key thing is whether the vaccine works-and the evidence to date is compelling that it does work quickly and well. The graph below shows the data from Pfizer’s vaccine studyof 43,661 people. It shows that the vaccine is 95% effective. A very positive finding is that protection occurs within 10 days of the first vaccine (note the early divergence of red placebo curve from blue vaccine curve). The booster dose at day 28 doesn’t appear to change the already high early protection; however it may enhance the durability of the effect. Show this graph to your most skeptical vaccine-concerned friend or family member. If you don’t want this type of protection it would be important for us to understand why.

graph showing data after first dose of covid vaccine

The vaccine provides protection within 14 days

This benefit comes at a very small risk (<4% incidence of short-lived, mild fatigue, fever or injection site tenderness). There is no risk of viral infection with the Pfizer and Moderna mRNA vaccines, which are the 1st two vaccines that Canada will see. While even mild symptoms may make a person worry they are developing COVID-19 infection, infection from these vaccines is not possible. The Pfizer and Moderna vaccines contain no virus; not even live-attenuated virus. These vaccine only contains the genetic code (mRNA) encoding one viral protein, the spike protein. The vaccine prompts our cells to make spike protein and then our immune cells make neutralizing antibodies and voila, we have immunity without ever being exposed to the virus!

The first vaccine to be given to members of the public has been administered in the UK-see below (click here) !

news article re first person to receive vaccine older lady and nurse

Fun fact-recipient number two in on the UK’s “V-day” was “William Shakespeare” (click here)!

We hope to have vaccine in Canada next week!  Health Canada approved the vaccine yesterday and we expect 249,000 doses will arrive in Canada and be administered in December (click here). The approval by Health Canada reflects their determination that the drug company provided compelling evidence not only that the vaccine works but that it is safe! Health Canada has an excellent track record of keeping Canadians safe (avoiding many drug related misadventures that other countries have suffered). When you are contemplating receiving a vaccine (likely being offered to the general public in April 2021) remember the risk/benefit ration. The risks are very small and the benefits are personal and societal protection form a potentially lethal disease. Vaccination is essential for the reopening of Canadian society: Indeed, the vaccine(s) is THE way (indeed the only way) we will be able to return society to normal. Mass vaccination, ideally 80% or more of all Canadians, is essential to establish herd immunity and to permanently reopen our economy. Vaccine’s will also be required for our borders to open. Even if vaccines are not made mandatory I’m reasonably sure that certain privileges will be tied to proof that one has been vaccinated.

4) Ontario has had 134,783 cases with 1983 new cases since yesterday, a total of 16,034 active cases and 829 people in hospital (click here): 

table showing data of increased covid cases and hospitalizations in Ontario

Ontario’s pandemic at a glance December 10th (click here

Ontario’s provincial rate (906.7/100,000 population) has doubled in the past month and is now almost 6X higher than in KFL&A (154.2 cases/100,000 population). However, for those following the local pandemic our prevalence has tripled since the summer! 

There were 1983 new cases today, up +1.5% from yesterday (click here). There have been 3871 deaths in Ontario since the pandemic began. On a positive note the SARS-CoV-2 reproduction number (number of people an infected person will infect) remains below 1.0, which if sustained will ultimately lead to a fall in cases and a flattening of the curve. The rate of positive SARS-CoV-2 tests in Ontario since the pandemic began is 1.89% but remains high at 3.6% today (although this is down from a peak of 5% ~2 weeks ago) (click here). 

graph of active and hospitalized cases Apr - Dec in Ontario

COVID-19’s large second wave in Ontario is still rising. Note the increase in hospitalizations (black line).

Peel (on Toronto’s western border) remains the hot spot in Ontario with 1872.7 cases/100,000 population. Toronto’s prevalence remains high at (1447.6 cases/100,000 population, up from 711 cases/100,000 population 2-weeks ago and ~9 times higher than Kingston) (see map below). Note the increase in red zones on the map below in the Toronto area-all these areas have an incidence of more than 500 cases/100,000 people. Ottawa also remains a hotspot, with a prevalence of 847.0 cases/100,000 population.

map of Ontario colour coded with current covid numbers

COVID-19 in Ontario: Dec 10th 2020

Neighborhood variation in COVID-19 in Toronto: Most of Toronto’s neighbourhoods are COVID-19 hotspots and have a cumulative prevalence of over 1000 cases/100,000 population (click here).

toronto waterfront and skyline with cn tower

Toronto remains a collection of neighbourhoods with vastly different COVID-19 realities due to differences in social/economic, racial and health circumstances. Although COVID-19 is increasing in the city as a whole, case load is widely variable amongst Toronto neighbourhoods. We should avoid travel to these hot spots from lower prevalence areas, like Kingston.

Since the pandemic began the Maple Leaf neighbourhood has had 4451 cases/100,000 residents, roughly 12X the burden of COVID-19 in the more affluent Beaches neighbourhood (380 cases of COVID-19/100,000 residents).

When one examines recent cases (i.e. those diagnosed since Nov 18th), case prevalence is still concerning-ranging from 46 cases/100,000 residents in the Annex to 1197 cases/100,000 residents, in Thistletown-Beaumont Heights (see below).

map of GTA with colour coded areas based on covid prevalence

COVID-19 infection rates in Toronto neighbourhoods since Nov 18th 2020

5) Canada’s second wave of COVID-19: We have had 437,310 total cases to date, with 3121 people currently in hospital (19.4% in ICUs) (click here)We have had 437,310 cases of COVID-19 in Canada and 12,725 deaths since the pandemic began (with 116 deaths since yesterday) (see below). There were 6292 new cases in Canada yesterday (see hotspots on map above). There are 72,070 active cases in Canada today and ~80% of all cases in the pandemic to date have recovered. There has been a 2.97% mortality rate amongst people diagnosed with COVID-19. Most cases of COVID-19 in Canada have been (in descending order), in Quebec, Ontario, Alberta and BC. Canada has done ~14 million tests and has a cumulative test rate positivity (since the pandemic began) of 3.11%. Ontario remains the province with the most testing (6.71 million tests, 1.98% cumulative positive rate).

map of Canada and graphs with various covid data

COVID-19 second wave sees a marked rise in hospitalizations-Dec 10th 2020

Rates of infection are high in all Western provinces (BC to Manitoba) but with introduction of more aggressive public health measures these provinces appear to be hitting a plateau (see Manitoba’s orange line below). The Manitoba government instituted a provincewide state of emergency under the Emergency Measures Act to protect the health and safety of all Manitobans, which appears to be yielding results (after a lag of several weeks) (click here).

graph showing increase in covid in Manitoba

COVID-19 in Manitoba Dec 10th 2020

Rates of new infection are low in all Maritime provinces, although highest in New Brunswick. There are outbreaks in the North in indigenous communities in Nunavut (click here). The rates in Nunavut are fortunately declining rapidly. Although Quebec still has a higher rate of test positivity than Ontario, its rate of case increase is flat and the total number of cases it accounts for, while still the greatest in Canada, is being approached by Ontario and Alberta (click here)

6) The COVID-19 global pandemic has seen ~1.58 million deaths and 69.2 million cases, up ~ 2 million since Monday (click here): There are now 69,221,147 cases globally and there have been 1,575,701 deaths. The number of cases has increased >4-fold since the beginning of August, 2020, when there were 16,296,790 cases globally. The pandemic hot spots are in the USA, India, Brazil, and Russia (click here). 

The USA with 15,441,001 cases and 290,219 deaths tops the COVID-19 list and accounts for ~21% of the global pandemic, while the USA only accounts for ~4% of the world’s population (see below).

world map, tables and graphs ranking world covid data

Global COVID-19 burden continues to accelerate: Dec 10th 2020

USA positive test rates (click here): In contrast with Ontario’s ~4% rate of positive tests, the USA has an average rate of positive COVID-19 tests of 11.2% (click here). There was a definite rise in rates of test positivity after a Thanksgiving that saw much of that country ignore public health guidelines about limiting travel and large group gatherings and the use of masks in indoor spaces (see blip on the right side of the graph). While vaccines are coming the data reminds us we can do irreparable damage in the meantime by ignore science and public health (and conversely that with attention to both we can bridge the next 3 months until vaccines are widely deployed).

graph showing the large increase of covid cases in USA after thanksgiving

The American Post Thanksgiving rise in case numbers is a lesson we should learn from

Rates of positive testing remain a staggering 51.5% today in South Dakota and over 31% in Arizona. The US-Canadian border will remain closed for routine travel at least until the December 21, 2020 and for other countries borders remain closed until Jan 21st 2021 (click here). That said, Canadians can still fly to America (although certain rules apply) and as discussed in my note last week, Canadian citizens can return to Canada from America, with a number of requirements, including quarantine) (click here).

driving directional signs at the Port Huron Canada US border

Regular reminders

KHSC bed capacityBed capacity at KHSC has contracted once again with only 72 beds available (versus 109 beds on Monday) (see below). Ventilator capacity also remains good. Elective care including procedures and outpatient clinics continues. We are doing contact tracing related to a 2 positive staff members on one a KGH ward (thus far all 15 contacts have tested negative) and one at Hotel Dieu. It remains very safe to come to our hospital and clinics and I encourage patients to advocate for themselves to get the healthcare they need!

graphs showing bed capacity at KGH

KGH capacity Dec 10th 2020

Use the Mobile Screening Tool to expedite clinic visits: Complete the COVID-19 pre-screening tool here and you will be able to “skip the line”: One way to safely expedite entry of patients into our facilities is to have all patients complete our pre-screening questionnaire before their clinic visit. This will screen out people who are sick and expedite entry to the facility for everyone. Reducing lines waiting to enter the clinics will be particularly important as colder weather arrives. The mobile screening tool only takes a few minutes to complete and you will receive an email with confirmation to bring with you, along with your appointment slip, in printed form or on your mobile device. To complete the mobile-screening in English, click here and in French, click here.

screen shot of pre screening hospital tool showing a hand clicking on a cellphone app

KHSC visitor policy: One of the hardest aspects of COVID-19 care in the hospital is the need to restrict visitors to ensure we don’t import COVID-19 into the hospital. A very few cases of COVID-19 can paralyze the hospital, particularly if they are brought in by visitors and then spread undetected. All details on the policy can be found using this link (click here). 

COVID-19 testing at Beechgrove Community Assessment Center: (click here): All COVID-19 test must be scheduled appointments (versus walk in). Our online system, Coconut, launched today and will assist in contact tracing. Appointments can be scheduled by telephone or by our new Eventbrite on line scheduling system. Before booking a test, individuals should complete the online tool to determine whether they qualify for testing (click here). The Beechgrove Complex is south of the King St. West/Portsmouth Avenue intersection. Signage will direct people through the Complex to the Recreation Centre building at 51 Heakes Lane for walk-in testing. Operating hours: Testing hours will return to 9 a.m. to 4 p.m. daily. To be tested you will require: A valid Ontario health card or a piece of photo identification. You must also wear a mask and maintain physical distancing at all times while in the walk-in line.

photo of covid nasal swab inserted in female nasal cavitythree young boys dressed up as doctors

Because health care workers (doctors and staff) are increasingly having to miss work because their children have been sent home from school or daycare with symptoms of a upper respiratory tract infection, we have arranged that their children can access expedited testing at Beechgrove . The goal of this service is simply to allow the healthcare worker to return to work as quickly as possible for the public good. The children of staff will be tested between 1230 -1300 by appointment, 7 days/week. The new program for families applies to children up to age 18, an includes children of staff and physicians who provide clinical care and service. Staff and physicians themselves should contact occupational health to book their testing appointment. To book an appointment for a child, KHSC staff should call 613-548-2376. Testing of clinical staff and faculty and their children is processed at the KHSC lab with an average turnaround time of less than 24 hours.

Increased outbreaks and deaths in Long Term Care facilities (LTC): We have 4060 LTC beds in KFL&A. As discussed in many prior notes, most COVID-19 deaths occur in people who are not only old but who are also frail and live in nursing homes and long term care facilities (LTC). As of today, the 2358 deaths in nursing homes (up 53 cases from Thursday) account for ~62.0% of all deaths in Ontario, click here. In the last month the rate of death amongst LTC residents continues to increase daily and is now >50/week! Outbreaks in nursing homes usually start with a person in the community (health worker or family) acquiring the infection and importing it into the facility. Thus, protecting LTCs is best done with a combination of reducing community spread of COVID-19 and ensuring single occupancy rooms in LTCs (as well as appropriate pay for PWS workers, provision of PPE and rapid testing capacity).

COVID-19 in toddlers and young children: (click here). 

Fortunately kids remain much less likely to be infected by SARS-CoV2 and when they are infected they usually become much less ill (click here). The vast majority of upper respiratory tract infections in kids in Ontario are caused by other viruses, like rhinovirus and RSV. Thus, health policy makers and parents of young children should recognize that while children are not immune from COVID-19 infection, infections are relatively uncommon and outcomes are usually excellent for those who are infected. 

two young boys in a classroom

Children are usually infected by an adult, usually in their home, rather than by other children. The number of cases in school age children (which includes teenagers) has increased dramatically to 4076 up substantially from 2714 2-weeks ago and 4 times the number from ~ 1 month ago (985 cases). 

female toddler holding an apple

Amongst younger children and toddlers COVID-19 remains relatively rare. In Ontario’s 5,500 licensed child care centres and over 120 licensed home child care agencies there is a very low COVID-19 burden (see table ). The rise in cases has been modest in these young children. 553 toddler age children have now been infected to date, up from 397 cases 2 weeks ago.

7) Good news:

1) KUDOS Kieran and KFL&A Public Health! We have all benefited from the excellent work of our local public health unit lead by Dr. Kieran Moore. Now their work has been recognized by Ontario’s auditor general (click here). According to the report, KFL&A Public Health, led by Dr. Kieran Moore, was one of only four public health units who met a target of 80% positive tests completed within two days (see below). Timely test results are critical to contact tracing and slowing the spread of COVID-19 in the community. KFL&A Public Health was joined by the public health units of Hastings and Prince Edward Counties; Leeds, Grenville and Lanark District; and Ottawa in meeting that threshold. KFL&A Public Health was also complimented for its excellent work with nursing homes. 

table ranking counties re covid work.  KFL&A highlighted

Bucks for Baskets-The DOM’s gift of the Magi

In a ‘normal year’, during the holiday season, the DOM graciously delivers holiday baskets to each of the medicine floors as a thank you from our doctors to the nursing and allied health staff for everything they do. Unfortunately, this year we were unable to do so due to the COVID-19 hospital restrictions. Although there are no baskets, we still wanted to shout loud and proud and say thank you for all that you do. You are an integral part of the Department of Medicine and keep us #Awesome!

We pondered for a bit how best to honour the collegial relationship we have with our care partners and decided to go ahead with our annual basket order hosting a Holiday Gift Basket sale – and by sale we mean selling the baskets to get donations to the Partners in Mission Foodbank, in exchange for a deluxe Holiday Gift Basket! Talk about turning lemons into lemonade!

Thank you to Brenda from Bursta Baskets (a local business) for creating the beautiful baskets and to everyone who has donated so far. To date we have raised $1755 for the local foodbank! 

We still have 2 Let it Snow baskets & 6 Decadent Deluxe Baskets left (see description below)! If you are interested in making a donation for a basket contact Karley Salsbury (karley.salsbury@queensu.ca) asap! 

photo of a gift basket with description of its contentsphoto of a gift basket with description of its contents

Stay well!

 

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