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February 1, 2021 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

HEADLINES

All patients admitted to KHSC will undergo Covid-19 testing

1) All about COVID-19 Vaccines: 

  • Update on global vaccination programs (click here
  • Results from Canada’s vaccine safety monitoring system provides reassurance of safety (click here), 
  • Updated FAQs about vaccination effectiveness against viral variants and safety of vaccination for people on blood thinners, with allergies or people who are immunosuppressed 
  • Updates on Canada’s vaccination program (click here)

2) KHSC has received no new COVID-19 patients from Toronto since initial transfers (but we remain on standby) 

3) New foreign travel restrictions (click here):

4) Ontario’s epidemic remains better controlled than in December with lower daily new case rates (1969 new cases yesterday), but a high rate of test positivity of 5.5% (click here).

5) KFL&A COVID-19 rates remain amongst the lowest in the province (see update from KFL& A Public Health)

6) Canada’s COVID-19 epidemic continues to improve: There have been 778,976 total cases to date and 90.6% are resolved. There were 3924 new cases yesterday and 51,818 active cases (a 21% decrease week-week) (click here) (click here). 

7) The COVID-19 global pandemic: the UK has passed Russia in cases due to rapid spread of the more contagious variant B.1.1.7-click here (click here):

8) Home ice advantage-a picture of Canada

________________________________________

1) All about COVID-19 Vaccines: 

  • Update on global vaccination programs (click here
  • Results from Canada’s vaccine safety monitoring system provides reassurance of safety (click here), 
  • Updated FAQs about vaccination effectiveness against viral variants and safety of vaccination for people on blood thinners, with allergies or people who are immunosuppressed 
  • Updates on Canada’s vaccination program (click here)

Here is a snapshot on how we are doing globally in administering vaccine (presented as # of vaccines administered/100 people/country). Israel is doing the best and Canada is in well down the pack)(click here). No vaccine came to Canada last week which did not help the cause!

Two graphs side by side, line graph on left with many coloured lines, bar graph on right with many coloured boxes

Global vaccine progress, Feb 1st 2021

COVID-19 vaccines are safe. Based on the clinical trials and experience in millions of people who have been vaccinated world-wide we can be reassured of both their safety and efficacy. All the side effects (called adverse events and abbreviated AEFI) are tracked and reported by the government of Canada. Here is what we have seen to date (no update since Jan 15th) (click here):

text and boxes with numbers re how many side effects from covid vaccine have happened

The vaccines in Canada are safe with only 27 serious adverse reactions in the >800,000 vaccines administered to date (and no fatalities). No data updates because few vaccinations last week.

Here are answers to some updated FAQs with answers to common questions about the COVID-19 vaccines.

FAQ 1) Does the vaccine work against new variants (mutations) in the SARS-CoV2 virus? Short answer YES. The slide below (from Dr. Evans) shows results from 144,000 participants in randomized clinical trials (RCTs, including both the vaccinated and the unvaccinated). In those receiving any active vaccine there are only 3 cases of severe COVID-19 (vs 37 in the control group). There were no deaths in people who were vaccinated with any of the vaccines versus 5 deaths in the control group. There were also no severe vaccine side effects or mortality. While this does not directly prove the vaccines protect against the variants these variants were about and likely are included in the data set. These are promising data (especially when combined with serologic tests that show the antibodies raised in people by vaccination neutralize variant viruses in the test tube). Thus, despite variant viruses the vaccines are lifesavers!

snapshot of excellent spreadsheet

Vaccines are safe and effective: RCT data

FAQ 2) I’m on a blood thinner, can I be vaccinated for COVID-19? Short answer YES. Here is a more detailed answer from an Canadian agency with expertise on the use of blood thinners, Thrombosis Canada

memo from Thrombosis Canada re covid vaccine

FAQ 3) I have a history of allergic reactions, can I be vaccinated for COVID-19? Short answer YES. Out of ~1.8 million vaccinations there have only been 21 reported episodes of anaphylaxis (the most serious type of allergic reaction). Most (70%) of these events occurred within 15 minutes of the vaccine (while the patient is still being monitored, as summarized in a Jan 6th MMWR CDC article). There were also 83 cases of non-anaphylaxis allergic reaction after Pfizer-BioNTech COVID-19 vaccination with symptom onset within the 0–1-day risk window. Most (87%) of these allergic reactions were classified as non-serious.

logo for Centeres for Disease control and prevention morbidity and mortality weekly report in blue coloured ink

So while there is not zero risk, the risk of severe allergic reactions to the Pfizer vaccine are low and manageable. Allergy testing is NOT necessary prior to COVID-19 vaccination even in people with history of allergies. It is important note that none of the people who developed anaphylaxis after vaccination died and most did not have a prior history of anaphylaxis (see table below). The incidence of anaphylaxis is lower still with the Moderna vaccine.

The adverse effects of the COVID-19 vaccines clinical trials are similar in vaccinated people vs people (in the clinical trial who got a placebo-saline injection) except for local pain at the vaccine site and increased muscle ache and headache, all of which were short-term (see below). This is a very good safety profile relative to other vaccines.

listing and percentage of side effects for Pfizer vaccine vs placebo

The CDC does advise against the use of the two mRNA vaccines for a very select group of people with the following allergy histories (click here):

CDC considers a history of the following to be a contraindication to vaccination with both the Pfizer-BioNTech and Moderna COVID-19 vaccines:

  • Severe allergic reaction (e.g., anaphylaxis) after a previous dose of an mRNA COVID-19 vaccine or any of its components
  • Immediate allergic reaction of any severity to a previous dose of an mRNA COVID-19 vaccine or any of its components (including polyethylene glycol [PEG])*
  • Immediate allergic reaction of any severity to polysorbate (due to potential cross-reactive hypersensitivity with the vaccine ingredient PEG)*

The table in blue below offers advice from the CDC on the issue of allergies and vaccines (see below). This is a reasonable approach and suggests careful monitoring for allergic response post vaccination; rather than avoidance of vaccination for most people with allergies.

summary of anaphylaxis and covid 19 vaccine

FAQ 4) I’m immunosuppressed, should I get vaccinated? This question has a less clear answer. First, be reassured is no virus (dead or alive) in the Pfizer or Moderna vaccines so it is not possible for a person to get infected from the vaccine. However immunosuppressed people were not included in the initial clinical trials. That said, they probably are safe to be vaccinated but this is more a matter of expert opinion. In Canada the National Advisory Committee on Immunization (NACI) currently advises that the COVID-19 vaccine should not be offered to populations excluded from clinical trials “until further evidence is available.” However, they also say (an immunosuppressed person or those with an autoimmune disorder can still be vaccinated if a risk assessment deems that the benefits of vaccine outweigh the potential risks for the individual.” (click here).

The British Society for Immunology recently issued a statement indicating that vaccination is safe in immunosuppressed people (click here), albeit the resulting immune response may be weaker. They remind us that because there is no virus in the vaccine there is absolutely no risk of acquiring COVID-19 from the vaccine.

Our own Dr. Mike Beyak (gastroenterology) nicely summarized evidence from a registry of ~4500 patients who were immunosuppressed for their inflammatory bowel diseases (Crohn’s disease and ulcerative colitis) at this morning’s Zoom Medical Grand Rounds (see below).

                                    ppt slide on overhead screenPresenter at podium with slides on overhead screen behind him

There was no increased risk of contracting COVID-19 in these 4500 patients. Apart for patients on prednisone, there was also no increased complications from COVID-19 when it occurred. Interestingly, some biologic therapies (antibody treatments for IBD) actually appear to reduce adverse outcomes in IBD patients who contracted COVID-19. This is not surprising since the truly bad outcomes in COVID-19 seem to occur in people who mount a hyper-aggressive immune response. 

Overall these data are good news for our many patients with rheumatoid arthritis, asthma and IBD who are on immunosuppressive therapies. However, since these people were not included in the vaccine clinical trials, it is advised they consult the physicians/clinic that is managing their care to inform their vaccine decision.

FAQ 5: How long can I wait after my first dose to get a second vaccine dose? The Ontario science table which deals with COVID-19 (on which our own Dr Evans participates) has looked at the efficacy of delaying the second vaccine dose to 42 days. It appears a second dose at day 42 is as effective in producing a neutralizing antibody response as when the dose is given at day 21 (the normal interval from dose 1). This more lenient 42-day protocol has been approved by Health Canada.

syringe and needle drawing vaccine from bottle

Vaccination roll-out update (click here): The roll out is moving along but encountering logistical challenges and supply chain problems (notably Pfizer stopped vaccine supply entirely last week and now is reducing supply for a month as it retools a factory in Belgium). To date we have not had to deal much with people declining vaccines; rather we are dealing with a pent up demand for vaccines that far exceeds supply. Mr. Trudeau has indicated all Canadians who wish to be vaccinated will be vaccinated by September (click here). 

As of today a total of 1,122,450 doses of COVID-19 vaccines (including both Moderna and Pfizer-BioNTech) have been delivered (no increase since Monday since no vaccine delivered to Ontario since then). Thus far, 85.6% of delivered doses have been administered. As of today, 960,429 Canadians have received at least one dose of an approved COVID-19 vaccine (see below). At least 113,334 Canadians are fully vaccinated, having received both required doses (click here).

map of Canada with each province labelled and the number of vaccine doses administered noted for each province

Vaccinations in arms as of Feb1st 2021

2) New foreign travel restrictions (click here): The government has made travel to the Caribbean and Mexico “difficult” and return flights to Canada are cancelled, potentially stranding people abroad. Air Canada, WestJet, Sunwing, and Air Transat have canceled air service to all Caribbean destinations and Mexico from Jan. 31st until April 30th, The goal of these polices are to reduce importation of variant viruses to Canada. 

photo of mom and son masked using hand sanitizer in an empty airport

The policy for returning Canadians is as follows (click here) and requires a negative COVID-19 test: Starting January 6, 2021 at 11:59 PM EST, air travellers 5 years of age or older travelling to Canada are required to provide proof of a negative COVID-19 molecular test taken, at their own expense, no more than 72 hours before the aircraft's initial scheduled departure time. Travellers who cannot provide proof of a negative test, or who test positive, will not be allowed to board, with limited exceptions. Canadians who are planning to travel abroad should consider how they will meet these requirements before departure, and make plans for the possibility of needing to extend their stay. Travellers who receive a negative test result and are authorized to enter Canada must still complete the full, mandatory 14-day quarantine

3) KHSC received no new COVID-19 patients from Toronto since the initial 4 ICU transfers over a week ago; but we remain on standby 

We remain on standby to receive patients from Toronto and Scarborough but no cases arrived over the past week since we received 4 ICU patients. Hopefully with a new MacKenzie hospital opening in Vaughan (click here) and flattening of the provincial COVID-19 curve transfers will not be necessary. 

4) Ontario’s epidemic remains better controlled than in December with lower rates of new cases (1969 yesterday), but a high rate of test positivity of 5.5% (click here).

In general things are markedly improved in Ontario since the lockdown. Daily case rates are hovering slightly below 2000 (1969 yesterday, see below). 

current numbers for cases, hospitalizations and deaths for Ontario

Since the pandemic began ~5% of infected people in Ontario have been hospitalized and 2.3% of infected people have died. We have had a 23% reduction in new cases for the week compared to the prior week. Likewise, hospitalizations have declined 10% (see below).

pink graph with text and arrows showing direction of cases deaths and hospitalizations going down

Peel (on Toronto’s western border) remains the hot spot in Ontario with 3412.9 cases/100,000 population, as measured form the beginning of the pandemic (click here). A look at recent infections (infections within the past 2 weeks, expressed as cases/100,000 population) shows that Peel is once again the leading site of infection:

Rate of cases/100,000 population in the past 2 weeks

Peel:354.9

Toronto:322.4

Windsor:296.8 

Ottawa:114.3

KFL&A:14.6

Cornwall: 162.4

waterfront photo of Toronto taken from the water showing CN tower and Rogers Place

Rates of COVID-19 infection in Toronto vary widely amongst neighbourhoods. The burden of COVID-19 disproportionately affects black, middle eastern and southeast Asian populations (relative to whites). Since the pandemic began, the Thistletown-Beaumond neighbourhood has had 7,558 cases/100,000 residents, ~ 10X the burden of COVID-19 in the Beaches neighbourhood (784 cases of COVID-19/100,000 residents). When one examines recent cases, those since Jan 6th 2021, case prevalence is still high, ranging from 67 cases/100,000 residents in St. Andrews-Windfield to 1036 cases/100,000 residents in Humbermede (click here).

We should avoid elective travel to and from these hot spots from lower prevalence areas, like Kingston.

5) KFL&A COVID-19 rates remain amongst the lowest in the province (see update from KFL& A Public Health)

The total number of cases in KFL&A since the pandemic began has increased 4 since Thursday and is now 667, not counting the prison outbreak. The local rise in cases seen in December has declined to a new low plateau (see graph below). There has only been one death of a KFL&A resident since the pandemic began. There are 11 active cases in the community, down 16 active cases since Thursday. There are 5 COVID-19 patient hospitalized at KGH (down from 5 last week). The KHSC lab did 2545 tests in the past 4 days. There were 17 positive tests, 10 from Lanark Leeds Grenville County and no positive tests locally in our lab (although there were a few local cases at public lab). Our lab’s positive rate is 0.7%. 

yellow bar graphs showing cases in KFL&A

COVID-19 rates remain low in KFL&A, Feb 1st 2021

Things are looking very good in SE Ontario, with only 32 active cases. The map below (courtesy of Dr. Gerald Evans) shows KFL&A in the green.

map of Ontario colour coded denoting areas with similar covid numbers

KFL&A in green has <7 COVID-19 cases/100,000 population

Bottom line: The vaccine will ultimately protect us; however, it will take months to get a critical mass of Canadians vaccinated. There is urgency for vaccination as we now have the more infectious UK variant in Ontario. Meanwhile we have to rely on good public health practices. This is the final leg of a marathon and the next 3-4 months will challenge us all to remain patient and follow policies that we acknowledge have harsh financial and social consequences. We are in a race against new viral variants that seem even more adept at infecting us. However, there is light at the end of the tunnel in the form of the vaccines.

black and white photo of tunnel with train tracks and daylight at the end of the tunnel.

6) Canada’s COVID-19 epidemic continues to improve: There have been 778,976 total cases to date and 90.6% are resolved. There were 3924 new cases yesterday and 51,818 active cases (a 21% decrease week-week) (click here) (click here). 

Our second wave of COVID-19 (orange line-top panel below) has been improving for several weeks, with a 21% decline in the weekly rates of new cases (see below). We are now seeing the expected fall in hospitalizations, 13% down last week compared to the week before (table below). ~90.6 % of all cases have already recovered. There have been 20,032 COVID-19 deaths thus far (a cumulative national case mortality rate of ~2.57%). Canada has performed 22.16 million COVID-19 tests with a cumulative test positivity rate of 3.51%.

pink coloured bar graph with text below and arrows pointing down

Decline in new and active cases this week in Canada (click here).

Rates of infection have plateaued in all Western provinces (BC to Manitoba) as a result of introduction of more aggressive public health measures. Saskatchewan too has now seen a decline in rates and assumed a new lower plateau trajectory. Rates in Ontario and Quebec (home to almost 63% of all Canadians) are experiencing a lockdown-induced decline. Rates of new infection have remained begun to decrease in New Brunswick. Infection rates remain flat in the other Maritime provinces. The outbreaks in the North have been controlled with few new cases in the NWT, Yukon, and Nunavut.

various graphs showing covid related data for Canada

Active cases (top graph, orange line) and ICU admission (bottom right red graph) are declining in Canada, Feb 1st 2021

7) The COVID-19 global pandemic: the UK has passed Russia in cases due to rapid spread of the more contagious variant B.1.1.7-click here ) (click here):

The global case burden for COVID-19 has increased by ~3 million since Thursday to 103,036,685 total cases with 2,229,601 deaths, a 2.16% case mortality rate. The UK has seen more than 100,000 COVID-19 deaths. The new variant is now the dominant form of the virus in Britain. While more contagious it is unclear whether the virus is more lethal once contracted. Other variants that have emerged include the B.1.351 variant in South Africa and the P.1 variant in Brazil. So far, studies suggest that antibodies generated through vaccination with currently authorized vaccines recognize these variants (click here).

The number of cases globally has increased >6-fold since early August, 2020, when there were 16 million cases. The pandemic hot spots are in the USA, India, Brazil, the United Kingdom and Russia. The United Kingdom has moved past Russa with 3,828,183 cases, most of which are now the UK variant of SARS-CoV-2. A positive note is the decline in the daily number of active cases (see bottom right orange graph).

world map with pink dots and ranking of countries leading with covid cases and deaths

Global COVID-19: New cases may have peaked (bottom right): Feb1st 2021 

The USA with 26,188,167 cases and 441,331 deaths tops the COVID-19 list and accounts for ~25% of the global pandemic (up from 21% pre-Christmas). The USA only accounts for ~4% of the world’s population (see below). There are as many cases in America as in India, Brazil, UK and Russia combined! The COVID-19 active case map (above) shows the high incidence of active infections in the US and South America, as well as in Europe (the bigger the salmon-colored dot the higher the active cases/100,000 population). The ONLY solutions to this are adherence to public health measures and rapid mass vaccination.

Improving USA positive test rates (click here): The USA has seen continued improvement in positive test rate for several weeks and is now at 8.1%, the lowest since mid-November 2020 (click here) (see below). California’s positive test rate has decreased to 6.7% whilst South Dakota’s rates remains very high at 20.5% (although this is a reduction to half of the rate at Christmas). For snowbirds: rates in Florida remain high (9.3% today). 

blue line graph running through pink and grey bar graphs

Improvement in positive test rates in the USA, Feb 1st 2021

The US-Canadian border closure has been extended until at least Feb 21st, 2021 (click here). That said, Canadians can still fly to America (certain rules apply) and as discussed in my note in early December, Canadian citizens can return to Canada from America, with a number of new requirements, including negative COVID-19 tests and quarantine, discussed earlier in this note, point #2).

border bridge with Cdn and USA flags in the forefront

Regular reminders

KHSC bed capacityBed capacity is adequate with 73 beds available (down 11 from Thursday) and good ventilator capacity (see graphic below). Our ventilator supply remains good; however, critical care beds are in short supply (see below). Medicine remains busy with 171 beds, not including ICU beds on Davies 4 staffed by the Medicine program. We are committed to providing care to the 99.9% of patients in SE Ontario who do not have COVID-19. In addition to acute care for heart attacks, strokes and trauma etc., we are continuing to provide elective care. We recognize that the term “elective care” is really a misnomer. Many “elective” patients have chronic pain and disability or suffer from cancer and other serious diseases and will not tolerate delay in care. We continue to encourage physicians to optimize the use of e-health visits. We are also reminding patients who are coming to clinics in person that unless it is essential (and approved) they need to come alone, to minimize crowding in our clinic waiting areas. That said, it remains VERY safe to attend appointments at our clinics or to come to hospital for needed care!

circular graphs showing bed capacity at KHSC

Use the Mobile Screening Tool to expedite clinic visits: Complete the COVID-19 pre-screening tool hereand 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 a tweet for the prescreening tool at KHSC finger scrolling on iPhone

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. If a family member is coming in from a high prevalence area they cannot enter KHSC (i.e. they will fail the screening question). There are exceptions made for exceptional circumstances; but this policy is necessary to prevent importation of infection to the hospital which would impair our ability to care for all patients. 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). Appointments can be scheduled using our 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 (click here).

animated photo of a female receiving a covid nasal swab testthree young boys dressed up as doctors with their arms crossed wearing stethoscope

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): 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 LTC. As of today, the 3529 deaths in nursing homes (up 77 deaths since Thursday) account for ~57.3% of all deaths in Ontario, click here. There are also ~ 900 active cases in LTC residents and 898 active cases in LTC staff (numbers which are continuing to decrease)! In the last month the rate of death amongst LTC residents has continued to increase daily and is now >100/week! Outbreaks in nursing homes usually imported by a person coming in from 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). It is because of these grim statistics (see below) that the province has prioritized vaccination of health care workers and residents of Ontario’s LTCs.

3 senior citizens wearing masks sitting at at table talking

COVID-19 in toddlers and young children: (click here). School is back (in 7 regions) and with this a return to reporting on COVID-19 in schools. Below is the new baseline report for school age children in publicly funded Ontario schools. School boards report every weekday from Monday to Friday. There have been 5146 students with COVID-19 since the pandemic began; 14 new cases in the past 2 weeks (see below).

group of teenagers sitting on a bench using iPads and iPhones

Here are the parallel data from licensed child care facilities in Ontario-where there have been 1091 children infected since the pandemic began, 170 new cases in the past 2 weeks. 

photo of young children sitting not the floor of a classroom

9) Home ice advantage: pandemic-proof playground picture.

It has been a long time since things were normal in Canada; however, there are reminders everywhere of the Canada’s beauty. This ice rink was in use yesterday and this morning reverberated with the echoes of skates cutting ice and puck on stick.

photo of orange and yellow sky, frozen lake with hockey nets and benches

Stay well (and keep your stick on the ice)! 

 

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