January 18, 2021 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
All patients admitted to KHSC will undergo Covid-19 testing
1) KHSC receives patients from Toronto
2) Provincial lockdown order for Ontario: Is it working yet? (click here)
3)Vaccine rollout-national and local update: here is the link to Canada’s COVID-19 vaccine tracker (click here).
4) Ontario’s epidemic is not under control (despite visible benefit from lockdown) with a rate of test positivity of 6.6%, 1571 hospitalized patients (394 in ICU) and 2578 new cases/day (click here).
5) COVID-19 rates continue to improve in KFL&A (see update from KFL& A Public Health)
6) Mask and eye protection update-update on KHSC policy
7) Canada’s COVID-19 epidemic: 711,194 total cases to date, 73,635 active cases and 18,038 deaths (a cumulative national case mortality rate of ~1.9%). To date 580,433 people have been at least partially vaccinated (click here)
8) The COVID-19 global pandemic: Global mortality now exceeds 2 million people with over 95 million cases in the pandemic to date (25% from the USA) (click here):
1) KHSC receives patients in transfer from Toronto hospitals (as we assist in decompressing their ICU and Medicine beds)
There has been a decision by the province to distribute Toronto cases to less congested regions, since their ICU capacity has been overwhelmed. They are beginning to import level 3 (intubated patients) from Scarborough General (which is at double their normal ICU load) to KHSC. We have already received 2 intubated COVID-19 patients and 2 more people are on their way. There are also 40 more patients who are not critically ill who are being sent out form the GTA to our region. The details of their illnesses are uncertain. We will move new level 3 (intubated) people to Davies 4, as capacity allows. The total numbers of patients likely to come from the greater Toronto area (GTA) over the next 3 weeks is unknown. If the COVID-19 pandemic plateaus we may only get 17 transferred level 3 patients; however, if we continue to see a rise in Toronto’s epidemic we could receive 40 intubated patients. This higher number would strain capacity at KHSC. As physician leaders, we will be working closely with the hospital to balance a need to be part of a provincial healthcare system while at the same time protecting the capacity to care for the 500,000 people in Southeastern Ontario who get care for critical illnesses like stroke and heart attack at KHSC.
2) Provincial lockdown order for Ontario: Is it working yet? (click here) The new Ontario lockdown rules (see last note), intensified a lockdown which began Dec 26th. Is it working? The answer is a qualified yes. Lockdowns do work to reduce COVID spread provided they are adhered to and are broad enough, and provided they are combined with targeted interventions in hot spot. Lockdowns that allow large factories to continue to run and don’t offer their workers sick leave are unlikely to stem case incidence in regions like Peel. While lockdowns work to slow viral spread, they do bring social isolation, impair health care access for non-COVID-19 diseases, exacerbate mental health challenges and create adverse economic consequences. As a piece of early evidence this pain is yielding some gain: the graph below shows a modest plateau in new cases in Ontario, coincident with the post-Christmas lockdown (see below).
Effects of lockdown: Active cases may have plateaued but hospitalizations are still on the rise
3)Vaccine rollout-national and local update: Here is the link to Canada’s COVID-19 vaccine tracker (click here).
Canada vaccine delivery to date: Jan 18th 2021
Thus far our amazing KHSC vaccine team has delivered 1956 vaccines, 250 by a new mobile pilot program that gets the vaccine out to our long term care facilities. All vaccines thus far have been given to LTC staff and residents. We have now received a second shipment of Pfizer vaccine that we will be administering in the coming week. Because of the Pfizer decision to retool its Belgium factory (with the goal of enhancing vaccine capacity in a month or so) (click here) there will be Canada-wide delays in vaccine supply (click here). On a more positive note, there will be Moderna vaccine arriving in south eastern Ontario soon. This vaccine will also be given to LTC residents per order of the province. The initial Moderna vaccine shipment will be going to the other public health units in south eastern Ontario, rather than KFL&A. We do not know yet when we will be vaccinating our faculty and staff. However, there has been strong advocacy for ensuring that our frontline workers and faculty get vaccinated as soon as possible by our CEO, Dr. Pichora; but the timing of this is being determined by the province.
An interesting update on the time interval between dose 1 and dose 2: Ontario’s 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 internal from dose 1). This more lenient protocol has been approved by Health Canada.
Important factors that guide the KHSC vaccine team:
- Prioritization of populations for vaccination as dictated by the province
- The clinic will run 7 days/week.
- No doses will be wasted. Any reserve vaccine capacity will be used to vaccinate heath care workers on an on call basis.
- KHSC is a regional centre for vaccine distribution so equitable access will be ensured for LTC workers and health care workers at other regional hospitals and clinics.
4) Ontario’s epidemic is not yet under control (despite a visible benefit from lockdown) with a rate of test positivity of 6.6%, 1571 hospitalized patients (394 in ICU) and 2578 new cases/day (click here).Ontario has had 240,364 COVID-19 cases, 2578 new cases since yesterday (a decline from many days over 3000 new cases). There remains a reduction in our positive COVID-19 test rate from 9.7% last Monday to 6.6% today. Ontario’s provincial rate is 1617/100,000 population, 5-times higher than in KFL&A (293.3 cases/100,000 population).
Ontario’s pandemic at a glance: Jan 18th 2021 (click here)
COVID-19’s large second wave in Ontario is resulting in many active cases (28,893) and high rates of hospitalizations (1571 in hospital today with 395 in ICU beds) (see below). The good news is that active case numbers have begun to plateau as a result of the lockdown (pink graph at top)
Most patients with COVID-19 are cared for on Medicine wards (gold above) and the balance are in ICU (black line in graph above) (click here). This ~4/1 ratio of ward to ICU admissions has been fairly constant throughout the pandemic. The government need to be mindful of this fact as they distribute resources to support pandemic care. Their rhetoric often focuses on Emergency Departments and Critical Care Units (which are important) and too often fails to mention Medicine Units, such as Connell 3 at KGH, where 75% of COVID-19 care is provided.
As has been true throughout the pandemic, it is young people (purple/pink in graph below) who account for most infections whereas almost all the mortality is in people over age 60 years.
Peel (on Toronto’s western border) remains the hot spot in Ontario with 3084.9 cases/100,000 population (click here). Toronto’s prevalence remains high at (2393.6 cases/100,000 population, ~3X the rate 1 month ago (711 cases/100,000) and ~9 times higher than Kingston, 293.3 cases/100,000). Windsor (2597.7 cases/100,000 population) and Ottawa (1172.3 cases/100,000 population) remain hotspots. Eastern Ontario, around Cornwall, continues to rise rapidly (1036.8 cases/100,000).
Neighborhood variation in COVID-19 in Toronto (click here).
Toronto remains a collection of neighbourhoods with vastly different COVID-19 realities due to differences in social/economic, racial and health circumstances. As can be seen in the graph below the burden of COVID-19 disproportionately affects black, middle eastern and southeast Asian populations (relative to Whites)
Although COVID-19 is increasing in the city as a whole, case load is widely variable amongst Toronto neighborhoods. Since the pandemic began, the Thistletown-Beaumond neighborhood has had 6815 cases/100,000 residents, ~ 10X the burden of COVID-19 in the Beaches neighbourhood (654 cases of COVID-19/100,000 residents). When one examines recent cases (i.e. those diagnosed in the past month), case prevalence is still high-ranging from 101 cases/100,000 residents in Mount Pleasant East to 1329 cases/100,000 residents, in Humber Summit (click here) (see map below with Humber Summit highlighted).
We should avoid elective travel to and from these hot spots from lower prevalence areas, like Kingston.
5) COVID-19 rates continue to improve in KFL&A (see update from KFL& A Public Health)
The total number of cases in KFL&A since the pandemic began is now 639, not counting the prison outbreak and there has only been one death of a KFL&A resident since the pandemic began. There have been 2 new cases since my Thursday note. On a positive note there are fewer active cases in the community (19) down markedly from 52 one week ago. There are 5 COVID-19 patient hospitalized at KGH (2 from Toronto). There are 3 people hospitalized in Hastings-Prince Edward County. There are only 71 active cases in SE Ontario, which is also good news. There are 7 outbreaks in the region.
Testing: In the last 4 days we have done 2508 tests for SARS-CoV-2 and 21 were positive (a rate of 0.8%). This contrasts with the province which is 6.6%. There is an increasing need for genomic surveillance to detect viral mutations. The mutations to date all appear to be susceptible to vaccine protection. However, the N501.V2 mutation (initially found in the UK) seems to be more infectious, especially amongst young children (stay tuned). It is highly likely to be vaccine sensitive (click here). The E484K variant found in South Africa, Brazil and Japan is still being studied to ensure that it does not have immune evasion capacity (click here).
Bottom line: The vaccine will ultimately protect us; however, it will take months to get a critical mass of Canadians vaccinated. 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. However, there is light at the end of the tunnel in the form of the vaccines.
6) Mask and eye protection update: We have intensified mask and eye protection recommendations to keep staff, healthcare workers and patients in LHSC safe. We are using N95 masks for health care providers who are in close contact with a COVID-19 positive patient. Risk assessment for the use of the N95s is done case by case for direct caregivers for COVID-19 patients. This likely is most relevant in areas like Connell 3, ICU and the Emergency room. We continue to use N95 masks for aerosol generating procedures.
A change is coming to our policy re: masking for outpatients visiting KHSC clinics. It has been noted that some patients are arriving with ill-fitting or soiled masks. Beginning soon, patients coming in for outpatient visits will receive a hospital-provided mask (if necessary).
In all patient care areas (including clinics) we now require that staff wear an eye shield or goggles and the use of level 2-3 masks (unlike the level 1 masks handed out upon entry to the hospital). The Level 2-3 masks and eye shields/goggles are available on the patient care units and in clinics. The type of mask is noted on the box it is stored in (important to note since there may also be some boxes with level 1 masks on wards). Please check the box you are taking your mask from!
7) Canada’s COVID-19 epidemic: 711,194 total cases to date, 73,635 active cases and 18,038 deaths (a cumulative national case mortality rate of ~1.9%). To date 580,433 people have been at least partially vaccinated (click here) Our second wave of active cases (orange line) has reached a plateau (and may be beginning to decline-too early to be sure).
COVID-19 in Canada: Jan 18th, 2021
86.5% of all cases have already recovered. There has been a 1.93% national mortality rate amongst people diagnosed with COVID-19 (see below).
Status of COVID-19 cases in Canada: Jan 18th, 2021
Most cases of COVID-19 in Canada have been (in descending order), in Quebec, Ontario, Alberta and BC (top left below). Canada has done 20.6 million COVID tests with a cumulative positive test rate of 3.4%. Ontario is nearing the same case number as Quebec. Ontario remains the province with the most testing (~8.9 million tests) and has a 2.7% cumulative positive rate). However, Ontario’s current daily positive rate is 6.6%.
Rates of infection are high in all Western provinces (BC to Manitoba) but with introduction of more aggressive public health measures rates in these provinces have plateaued (which is the intended outcome of the Dec 26th Ontario lockdown). Saskatchewan is seeing another rise in rates (I’m not sure why). Manitoba remains a great example of the benefits of a lockdown as a means to control active case spread pre vaccine (see below).
Active cases decline in Manitoba in response to a lockdown (orange line)
Rates in Ontario and Quebec (home to almost 63% of all Canadians) appear to have hit a plateau but another week of observation is needed to be sure. Rates of new infection have increased suddenly in New Brunswick (see below) but 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.
An increase in active cases in New Brunswick (orange line)
7) The COVID-19 global pandemic: Global mortality now exceeds 2 million people with over 95 million cases in the pandemic to date (click here): There has been a total of 2,034,705 million deaths and 95,243,401 million cases since the pandemic began.The number of cases has increased ~6-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, with the UK, France and Turkey in hot pursuit! (click here).
Rising global COVID-19 death toll exceeds 2 million: Jan 18th 2021
The USA with 23,964,891 cases and 397,808 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 and Russia combined! The COVID-19 active case map (above) shows the high incidence of infection 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.
USA positive test rates and extension of border closure (click here): The USA, has an average positive test rate of 10.9% (click here). California has a positive test rate of 11.4% whilst South Dakota remains at a staggering 30.7% rate of test positivity today. For snowbirds-rates in Florida remain high (11% today)-see below.
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 requirements, including quarantine) (click here).
KHSC bed capacity: Bed capacity has reduced since last Monday when it was 110. There are now only 80 beds available (see graphic below). Our ventilator supply remains good; however, critical care beds are in short supply.
We are only reducing elective care to the extent required, ensuring we provide care to the 99% of patients who do not have COVID-19. The term “elective care” is really a misnomer-many “elective” patients have cancer and other serious disease which 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!
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: 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 and this family presence policy will be updated by the end of the week (to make it clear who grants final decisions on exceptions that allow access). 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). 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).
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 3150 deaths in nursing homes (up 87 deaths since Thursday) account for ~58% of all deaths in Ontario, click here. There are also ~ 1615 active cases in LTC residents and 1272 of active cases in LTC staff! In the last month the rate of death amongst LTC residents continues 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.
COVID-19 in toddlers and young children: (click here). No updates since Dec 21st since on-site schooling does not resume until later in January.