December 7, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
1) COVID-19 volumes have dramatically increased in KFL&A (see update from KFL& A Public Health)
2) Why should you get vaccinated?
3) Ontario has had 129,234 cases with 1925 new cases since yesterday, a total of 16,034 active cases and 725 people in hospital (click here):
4) Canada’s second wave of COVID-19: 419,020 total cases, with 6264 new cases since yesterday and a rapid spike in infection in western Canada and Nunavut (click here)
5) The COVID-19 global pandemic has seen ~1.45 million deaths and 67.4 million cases, up ~ 3 million cases since Thursday (click here)
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) COVID-19 volumes have dramatically increased in KFL&A related to a super spreader event (see update from KFL& A Public Health): There have been 30 new cases in the region since my note on Thursday. There are 55 active cases in the region, up from 16 one week ago. Unfortunately, the rise in cases in KFL&A is due to a 1-2 superspreading events (currently being contact traced). These new cases include people in all age groups, with 3 cases in people over age 80 years. Infections in the elderly usually foreshadows hospital admissions. Public Health will be providing details on this later today. Superspreading events are situations where >50-100 cases arise from one event, usually assembly of large groups or travel to COVID-19 hot spots. Details of the latest cases in KFL&A will be forthcoming from Public Health later today. This is the largest cluster of new cases in our region since the pandemic began.
The total number of cases in KFL&A since the pandemic began is now 308 with 116 active case active cases in southeastern Ontario, also the highest number since the pandemic began. There are 6 regional outbreaks in KFL&A. There is 1 person hospitalized in southeastern Ontario and that person is in Lennox, Leeds Greenville. All local COVID-19 patients are recovering in the community and there are no inpatients in KGH (see update from KFL& A Public Health).
In the past 4 days our lab has done 2494 COVID-19 tests. There were 27 positive tests, including 8 from the Kawartha area, 14 from Lennox, Leeds Greenville and 5 from KFL&A. The community assessment center is seeing increased testing volume, related to the rise of cases.
There has been another community acquired infection of a staff members at KGH (after 2 last week). This person had 15 high risk contacts but the infected person had been scrupulously following workplace isolation pre-infection. In addition the infected person did a great job summarizing all their contacts, making contact tracing feasible and fast! All 15 contacts have been tested for COVID-19 and all have been negative to date. As with the 2 staff infected last week. this individual acquired their infection in the community. This is a reminder that while our hospital is a very safe environment in which to work and to receive care, we healthcare workers need to be cautious in the community and limit our exposures.
KFL&A sees a rapid rise in cases: Dec 7th 2020
- 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.
2) Why should you get vaccinated?
It’s will protect you from COVID-19: In Pfizer’s vaccine studyof 43,661 people, the vaccine has thus far been 95% effective in preventing COVID-19. The vaccine’s benefit was evident within 28 days after the first dose (this vaccine requires 2 doses 4 weeks apart). 170 confirmed cases of COVID-19 were evaluated in the vaccine trial. There were 162 infections observed in the placebo group versus only 8 in the vaccine group. Equally important, 9 of 10 cases of severe COVID-19 disease occurred in the placebo group. The benefits were observed consistently, regardless of age, gender, race and ethnicity. Observed efficacy in adults over 65 years of age was over 94% (click here). Unlike the influenza virus which mutates each year (limiting the effectiveness of vaccines to 50-70% and requiring new vaccines be invented each year), the virus that causes COVID-19, SARS-CoV-2, seems fairly stable. This means a vaccine could have broad and long-lasting effectiveness! Of course, we will need to monitor this over time.
It’s safe: Pfizer looked at adverse effects of the vaccine in a randomly selected subset of 8000 people. Most side effects were mild and occurred early after vaccination. The only significant adverse effects were fatigue (in 3.8% of people) and headache (in 2.0% of people). Older people reported fewer and milder adverse effects. Some people experienced pain at the injection site, fever, fatigue, sore muscles and headaches, lasting only a few days. However, even mild symptoms may make a person worry they are developing COVID-19. That is not the case! Indeed, it’s not possible; because the Pfizer and Moderna vaccines contain no virus; not dead virus; not even live-attenuated virus. The vaccine only contains the genetic code (mRNA) encoding the viral 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 fact that the vaccine is already approved in England, after they scrutinized the data from Pfizer, is encouraging. Regulatory approval in Britain was based on the lack of significant adverse effects in a 2 month follow-up period. We could wait longer; but as everyone knows, the pandemic is destroying the global economy and killing people. Thus, time is of the essence and we need to get vaccines in arms. Admittedly, we are only 2 months into a 2-year vaccine trial so more safety, efficacy and duration of benefit data will be forthcoming, month by month for the next 2 years. This same process will play out for the other 4-5 vaccines being studied, with Moderna being next in line for Canada.
Canadians will not be the first to receive the vaccine: I’m personally not thrilled about adopting a “never first” motto; but it does have one upside in this case. Countries like Great Britain and the USA, will be ahead of us. Thus, there will be valuable, practical, real-world safety data for us to learn from. This will hopefully reassure those who are open to vaccination but who are a bit fearful/anxious.
The regulatory agency of Great Britain reviewed the evidence for Pfizer’s vaccine and found it safe and effective and so licensed it for use in Great Britain (click here).
Finally, before each vaccine is approved in Canada all the relevant data will be reviewed by our regulatory agency, Health Canada. New vaccines will only be approved if they find compelling evidence not only that it works but that it is safe.
It will protect your friends and family Vaccines are the reason we don’t have small pox. Vaccines are why children don’t suffer from measles, mumps and rubella. Vaccines reduce or eliminate shingles and prevent meningitis. Vaccines prevent cervical cancer. They do all these good things safely and cheaply and have done so since it was recognized that materials from a mild disease (cowpox), which infected milkmaids, could prevent a very serious disease (smallpox) (click here). Smallpox affected all levels of society. For example. in the 18th century in Europe, 400,000 people died annually of smallpox, and one third of the survivors went blind. Edward Jenner recognized that he could use materials from a cowpox blister to create an effective vaccine to prevent smallpox. Fun fact: vaccinations comes from the Latin vacca, meaning cow! Jenner was not the first to vaccinate but his 1798 book gave the technique its name, and led to its popularization and the eventual eradication of smallpox!
It would indeed be ironic if modern society, in which 20% of people say they have reservations about being vaccinated, failed to learn from Jenner and over 220 years of experiencing about the virtue of vaccination. The data suggest that people are more likely to talk the vaccine if they know its effective (see below-click here)…and the COVID-19 vaccines are!
In Canada ~10% of people indicate they are unsure if they will accept vaccination. On the more positive side, 76% of respondents in the Statistics Canada survey indicated they would likely get inoculated if and when a vaccine is ready. 14% said they were somewhat or very unlikely to do so. (click here).
The Astra Zeneca COVID-19 vaccine also appears (unpublished data) to prevent viral transmission. If confirmed this would mean that when you protect yourself you are simultaneously protecting others. Moreover, even if the vaccine simply creates large numbers of people in the population who are immune (i.e. have neutralizing antibodies) this will create “herd immunity” and help keep the unvaccinated safe. It is estimated that if we can vaccinate over 70% of the population we will also indirectly benefit these vulnerable people.
Vaccination is essential for the reopening of Canadian society: The vaccine will return society to normal and thus is essential for 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.
Limitations: While the vaccine trials have enrolled huge numbers of people the total observed infection in the trial (placebo arm and vaccine arm) are just a few hundred. More time will be required to confirm the high apparent level of effectiveness. We also don’t know how long the protection will last. Finally, we don’t have data on use of the vaccines in children and pregnant women. Notwithstanding these limitations it’s a welcome holiday miracle that we have several effective vaccines heading our way in the first quarter of 2020.
Bottom line: Once approved, we can be confident the vaccines are effective and safe. Please be prepared to take yours!
3) Ontario has had 129,234 cases with 1925 new cases since yesterday, a total of 16,034 active cases and 725 people in hospital (click here):
Ontario’s pandemic at a glance December 7th (click here)
There were 1925 new cases today, up +1.5% from yesterday (click here). There have been 7858 hospitalizations, and 3798 deaths in Ontario, since the pandemic began (up 6.2% and 3.0% since yesterday, respectively). 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 4.0% today (although this is down from a peak of 5% ~2 weeks ago) (click here).
COVID-19’s large second wave in Ontario is still rising. Note the increase in hospitalizations (black line).
Ontario’s provincial rate (869.4/100,000 population) has doubled in the past month and is now almost 6X higher than in KFL&A (141.5 cases/100,000 population). However, for those following the local pandemic our prevalence has almost tripled since the summer!
Peel (on Toronto’s western border) remains the hot spot in Ontario with 1789.5 cases/100,000 population. Toronto’s prevalence remains high at (1396.3 cases/100,000 population, up from 711 cases/100,000 population 2-weeks ago and ~9 times higher than Kingston) (see map below). Ottawa is also a hot spot at 816 cases/100,000 population (click here). Ottawa also remains a hotspot, with a prevalence of 836.6 cases/100,000 population.
COVID-19 in Ontario: Dec 7th 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 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. For example, since the pandemic began the Maple Leaf neighbourhood has had 4391 cases/100,000 residents, roughly 12X the burden of COVID-19 in the more affluent Beaches neighbourhood (366 cases of COVID-19/100,000 residents).
When one examines recent cases (i.e. those diagnosed since Nov 16th), case prevalence is still concerning-ranging from 39 cases/100,000 residents in the Annex to 1622 cases/100,000 residents, in Thistletown-Beaumont Heights- a 40-fold difference! (see below).
We should avoid travel to these hot spots from lower prevalence areas, like Kingston.
4) Canada’s second wave of COVID-19: We have had 419,020 total cases, with 6264 new cases since yesterday and a rapid spike in infection in western Canada and Nunavut (click here): We have had 419,020 cases of COVID-19 in Canada and 12,725 deaths since the pandemic began (with 76 new deaths since yesterday) (see below). There are 69,454 active cases in Canada today and ~80% of all cases in the pandemic to date have recovered. There has been a ~3% 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 13.6 million tests and has a cumulative test rate positivity (since the pandemic began) of 3.03%. Ontario remains the province with the most testing (6.6 million tests, 1.93% cumulative positive rate).
COVID-19 in Canada Dec 7th 2020
Rates of infection are rapidly rising in all Western provinces (BC to Manitoba) whereas they are rising more slowly) in Quebec and Ontario. Manitoba and BC appear to be hitting a plateau; but rates of infection in Alberta and Saskatchewan (see below-orange line) are continuing to rise.
COVID-19 in Saskatchewan Dec 7th 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 (see graph below) (click here)
5) The COVID-19 global pandemic has seen ~1.45 million deaths and 67.4 million cases, up ~ 3 million since Thursday (click here): There are now 67,440,864 cases globally and there have been 1,541,661 deaths. The number of cases has increased 4-fold 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 14,883,966 cases and 283,211 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).
Global COVID-19 burden continues to accelerate: Dec 7th 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 10.4% (click here). Rates of positive testing remain a staggering 49.7% today in South Dakota and over 30% 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).
KHSC bed capacity: Bed capacity at KHSC is reasonably good (109 beds available vs 89 beds on Thursday) (see below). Ventilator capacity also remains good. Elective care including procedures and outpatient clinics continues. We are doing contact tracing related to a positive staff member on one ward but thus far all 15 contacts have tested negative. 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!
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.
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.
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 2305 deaths in nursing homes (up 52 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! 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.
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 3531 up substantially from 3330 from Thursday and almost 4 times the number from ~ 1 month ago (985 cases).
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. 487 toddler age children have now been infected to date, up from 375 cases 2 weeks ago.