January 4, 2022 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
Let’s start with three big stories: 1) the new Ontario Public Health restrictions, notably a 2 week pause on in class education and a reduction in elective hospital-based health care 2) The likelihood that omicron is more infectious, less lethal and that it may paradoxically (after initial pain) help end the pandemic, and 3) clarity on the need to maintain ambulatory health care services for the good of the 99% of people who do not have COVID-19.
1) New Ontario Public Health rules It may feel like “old news” but Ontario just instituted significant tightening of public health restrictions yesterday, most importantly closing schools for on-site learning for at least two weeks (details here). This decision was taken because of rapidly rising rates of new cases and a concerning increase in hospitalizations (see tweet below).
The decision to close schools is a bitter pill for parents of school-aged children. While this is not the right forum to debate the decision; it is clear that parents are struggling to “home school” with limited warning. We will need to ensure this school closing is brief both for the overall well-being of our children and to allow us to staff key businesses and hospitals. We can’t run hospitals in the long term if parents (our staff, trainees and faculty) are obligated to stay home to care for their children
On January 5, 2022 the Chief Medical Officer of Health reinstated Directive 2 for hospitals and regulated health professionals. This directive instructs hospitals to pause all non-emergent and non-urgent surgeries and procedures in order to preserve critical care and human resource capacity. That said, ambulatory care must continue full steam ahead to avoid harm to patients and we have a moral obligation to continue to provide acute care to the maximum allowable capacity!
2) The second story in the new items below (could omicron be good news?) offers hope this will be a short absence from the classroom. In the meantime, we will as a Department do our utmost to support our staff, trainees and faculty with school-age children. The acronym FUSS describes the approach we are taking to handle school closures. I encourage Flexibility, Understanding, Support & Stability for staff, trainees & faculty. This may involve granting more work from home options, supporting more flexible work hours and definitely requires some compassion and good humor!
3) Ambulatory care of the 99% continues: Ambulatory care is open for business! Despite new restrictions from Ontario Health this week, which have reduced acute care at KGH (and all Ontario hospitals) to create capacity for anticipated or existing cases of COVID-19, it is “business as usual” for ambulatory clinics and procedures at the Hotel Dieu site. It is critical that we continue to see patients in person whenever possible. Omicron likely results in milder disease than prior variants. Thus, while we need to prepare for the possibility of rising omicron cases hitting our hospital we would be unwise (and the public will suffer) if we forget that delayed care for the 99% of people who have diseases like heart & stroke disease, cancer and critical surgical diseases will definitely cause morbidity and mortality. The Department of Medicine and the KHSC leadership are committed to keeping HDH running to serve the public! As always, should KHSC be called to receive transferred COVID-19 patients from other sites, or should in-patient capacity require redeployment of ambulatory clinic staff, we will pivot and decrease our outpatient care. Meanwhile, my request to all doctors is, please keep your outpatient clinics running at full capacity!
1) KFL&A update: Wave 4 rising due to omicron variant with 108 new cases/day, positive test rates ~16%,2214 active cases (> double the number a week ago), 15 patients hospitalized (most identified by surveillance swabs rather than symptoms) despite 83.4 % of people over age 5 years having >2 vaccine doses.
2) The Omicron variant: Why a more infectious but less lethal coronavirus may help end this pandemic-Lessons from South Africa
3) Ontario’s 4th wave rising: New and active cases are up a record 158% and 168%, respectively. While hospitalizations rose 89%, deaths remain relatively stable (up 3%)
6) The global pandemic is not yet controlled: ~292.7 million cases and 5,451,403 deaths to date with widely varying cases fatality ratios (from Canada at 1.35% to Yemen at 19.6%)
7) Questions of the day:
- A) I had 2 Moderna vaccines (or 2 Pfizer vaccines) initially: Can I take the other brand for my booster? Short answer YES!
- B) Is it safe for your heart to get vaccinated if you are under age 40 years? Short answer, Yes.
- C) Do the current vaccines work against Omicron? Yes-especially if you get the 3rddose booster.
- D) For asymptomatic, staff who have been exposed to an infected person-When can I return to work at KHSC?
1) KFL&A update: Wave 4 rising due to omicron variant with 108 new cases/day, positive test rates ~16%,2214 active cases (> double the number a week ago), 15 patients in KFL&A hospitalized (most identified by surveillance swabs rather than symptoms) despite 83.4 % of people over age 5 years having >2 vaccine doses.
Fortunately hospital admission’s related to COVID-19 at KHSC remain stable from last week, with 14 admitted people, 5 of whom are in intensive care. Interestingly, many of the COVID-19 cases are milder (thus far) and most were detected by surveillance testing (rather than the patients having been admitted with classic COVID-19 symptoms).
On a positive note, the rise in omicron cases (blue line-below) has not been accompanied by an increase in admissions across SE Ontario (much like the case in South Africa as discussed elsewhere in this note).
The medical wards remain very busy with 190 in-patients (see below). We have adequate ventilators and also have capacity to handle our regional acute care needs. That said surgeries and any elective acute care is being reduced as required by Ontario Health’s Directive 2 to maintain bed capacity by Ontario Health. We continue to struggle with the perpetual problem of loss of beds to the housing of Alternate Level of Care people (ALC). ALC people are people who do not require hospitalization but rather are in hospital because they lack a spot (or decline a spot) in a retirement home or nursing home and/or cannot access community social/health services adequately to meet their care needs. Today, ALC people occupy a precious 72 beds at KHSC! This does not benefit these people and limits our capacity to provide acute health care (read more here).
A snapshot of the Medicine service at KHSC-busy times!
2) The Omicron variant: why more infectious but less lethal may be just what we need to end this pandemic-Lessons from South Africa
The omicron variant was discovered in Botswana and South Africa in Nov 2021. It rapidly became the dominant form of SARS-CoV-2 (the virus that causes COVID-19) in those countries. By mid-December the New York Times reported there were 23,000 omicron cases/day in South Africa. With the recent Omicron-Induced Ontario shut down of schools, gyms and restaurants you can be forgiven for thinking the worst; but omicron may offer a silver lining.
Restrictions to the operation of schools, businesses and hospitals are painful, carrying grave psychological, fiscal and health consequences. These sacrifices make sense only if they are brief, targeted, and necessitated by the lethality of a virus. There is emerging evidence from South Africa that the very high rate of infection that this variant causes is not accompanied by the expected increase in deaths and hospitalizations. For example, since the beginning of the pandemic there have been ~91,000 deaths out of 3.4 million COVID-19 cases in South Africa, a 2.67% case/fatality (mortality) rate. In contrast on the past month, the period during which Omicron has been the dominant viral strain, there have been 1284 deaths out of 468,233 cases, a 10-fold lower mortality rate (0.27%)! Also encouraging rates of COVID-19 are rapidly declining in South Africa for the past 2 weeks! It appears this variant may be burning itself out (graph below). One interesting factoid is omicron’s mutations seem to make the virus target the bronchi (the main airways) more than the lungs themselves. Bronchitis is less serious that pneumonia and this mutation and the related change is target tissue may underlie the observed reduced lethality of this form of COVID-19. This mutation was acquired form a pre-existing coronavirus.
COVID-19 cases falling rapidly in South Africa-Has Omicron burnt itself out?
I acknowledge that there may be other explanations for the apparently favorable omicron data from South Africa. For example, omicron may infect younger people preferentially (and they always have better outcomes than the elderly). Also, in recent months, even in South Africa, more people have been vaccinated now than in the beginning of 2021 when mortality rates were higher; however the vaccination rates in South Africa remain low at 27% (Figure below)! So while there are other interpretations of the data, the simplest interpretation is that this omicron variant is more infectious but less lethal variant.
The really good news is that (in South Africa at least) the death rates have remined low despite the huge numbers of omicron infections! (See graph below).
Indeed, this appears to hold true in our own region (KFL&A), where despite logarithmic increases in cases number our hospitalization rates are not substantially increased. For example, as of Jan 3 we had 2214 active cases (>100/day) and yet there remain only 15 people hospitalized with COVID-19; similar to the numbers we had pre-omicron (and most detected by surveillance). In Canada overall COVID-19 case rates have risen logarithmically since omicron arrive (graph below).
COVID-19 cases have sky-rocketed in Canada due to omicron (note rise in Dec 2021-Jan 2022).
However, as in South Africa, deaths in Canada have not risen substantially. (graph below)
Death from COVID-19 in Canada-note lack of a rise with omicron in Dec 2021.
Moreover, hospitalizations, though increased in a concerning manner, are not increased as rapidly as would have been predicted with prior versions of this virus, like the delta variant (graph below).
Hospitalizations from COVID-19 in Canada-note blunted rise with omicron in Dec 2021.
This is not to diminish the severity of the negative impact that omicron is having on infected people (and the larger impact it is having on the function of society); however, we need to recognize a potential change in our viral foe and adapt our policies. If it proves to be a more infectious but less lethal virus our public health response will need to evolve our approach from containment to mitigation.
There are many viruses which are widespread and which only occasionally cause serious disease, like rhino viruses, adenoviruses, Epstein-Barr virus, and more. These endemic viruses causes self-contained illnesses (usually) and thus don’t require intrusive public health measures (we just stay home while feeling sick, increase hand washing and use symptom-targeted OTC medicines while at home). Since so many people are being infected it is plausible that omicron may lead to broader immunity in society and, when coupled with vaccine-induced immunity, get us to the point where coronaviruses are less of a plague. Omicron may play a role in getting us to the point of herd immunity. Time will tell, but I find the data to this point mildly encouraging. It appears the novel coronavirus is in the process of transforming itself into a less severe infection. This may be residual holiday optimism; but a little optimism is needed in wave 4!
3) Ontario’s 4th wave rising: New and active cases are up a record 158% and 168%, respectively. While hospitalizations rose 89%, deaths remain relatively stable (up 3%).
So what to do? At this point we have little choice but to adhere to public health rules for the next 2 weeks. By reducing assembly, respecting physical distancing and social distancing and attention to the use of masks and hand hygiene case numbers will drop, as they always do with this virus. Please ensure you and your children are vaccinated and if you are eligible (> 18 years and 84 days from dose 2 of vaccine), get your 3rd dose booster shot. Our “end game” is predicated on a mixture of vaccines, public health and perhaps the mutation of this coronavirus into a more infectious but less lethal pathogen.
Cases in Canada are rising
Canada’s part of the pandemic is worsening as the orange line showing the rise in new cases shows (orange line below). Also note hot spots with many active cases, like Newfoundland and PEI (orange part of bar graph, top left). That said, COVID-19 cases are up across the entire country, and its largely omicron, which has emerged as the dominant SARS-CoV-2 viral variant, replacing the delta variant.
COVID-19 in Canada-a snapshot on Jan 4th 2022
78.9% of people 5-years of age and older have had at least 2 vaccination doses (see graph below). Canada has had 2.29 million cases of COVID-19 since the pandemic began. The case mortality rate remains ~1.35% with 30,399 deaths. We have administered a total of >68.4 million vaccines!
Vaccines administered as of Jan 3rd 2022
The graphic below shows the number of people receiving one or more vaccine.
However, vaccination rates remain appallingly low in low-income countries, many of which are in Africa These vaccine deserts allow unnecessary human death and suffering and have allowed the virus fertile ground to mutate, the genesis of the Omicron variant. We need to learn to help ourselves by helping others!
Vaccine deserts remain (note countries with <1 dose per person): it is past time for rich countries to share vaccines!
Vaccines are safe: You may be interested in this recent blog, “Vaccines for COVID-19: Why are some Canadians allergic to the truth?” The blog reminds us how effective vaccines are (see graphic below) and how rare true allergic reactions are.
In addition to many clinical trials showing safety, the safety record of vaccines has been established in the real world. The complication rates remain very low based on Canadian data, which show that vaccines are safe (click here for Canada’s safety data), as well as being effective against all forms of the coronavirus. Getting vaccinated reduces your risk of infection, hospitalization, and death. It also makes you less likely to transmit the virus to others. Vaccination carries a very small risk of serious adverse reactions and virtually no risk of death.
The serious complication rate of COVID-19 vaccines remains low in Canada (11 serious adverse events per 100,000 vaccines administered). Data as of December 17th, 2021
6) The global pandemic is not yet controlled: ~292.7 million cases and 5,451,403 deaths to date, with widely varying cases fatality ratios (from Canada at 1.35% to Yemen at 19.6%)
Here is today’s map of the global pandemic. Daily cases are rising (red graph) but deaths have begun to decline (white graph). It is uncertain if this fall in mortality reflects the impact of vaccines, omicron’s lower mortality rate or other factors, such as under-reporting Vaccine administration remains high (green graph), albeit heterogenous in distribution (low in Africa).
Today I show the case-fatality ratios (the% of infected people that die-column to right of map), which is 1.35% in Canada. However, in some countries case fatality rates exceed 5%, like Egypt (5.6%), Ecuador (6.1%), Sudan (7.1%). Mexico (7.5%), Peru (8.8%), Vanuatu (14.2%), and Yemen (19.6%).
Global COVID-19, Jan 4th, 2022
7) Questions of the day:
- A) I initially had 2 Moderna vaccines (or 2 Pfizer vaccines)-Can I take the other brand for my booster? Short answer YES!
- B) What is the risk of myocarditis and pericarditis with the vaccine and does it increase with a second dose of vaccine? A Danish population-based study of almost 5 million people study showed that while there is an association between myocarditis and pericarditis and the miR vaccines (particularly with Moderna, mRNA-1273) overall the vaccines reduce cardiac death. Moderna’s vaccine increased the incidence of these self-limited inflammatory conditions of the heart muscle and lining in men and women (especially in those between ages 12-39); however the Pfizer vaccine increased the incidence only in women. The table below shows the increased risk of developing one of these complications (1.48 increased risk vs no vaccine for Pfizer and 6.25 increased risk for Moderna vs no vaccine). The risk of developing these complications is low and the outcomes are excellent (i.e. cases resolve in almost all cases).
This paper did not find that a second vaccine dose of BNT162b2 (Pfizer) was associated with a higher rate of myocarditis or myopericarditis.
Importantly the risk of cardiac arrest and death was reduced in vaccinated people (green box in graph below) vs unvaccinated people!
Advice: Get vaccinated and don’t let the small risk of reversible heart inflammation (1/10,000-1/100,000 risk) deter you! Overall you are much safer from a heart perspective if you are vaccinated!
C) Do the current vaccines work against Omicron? Yes-especially if you get the 3rddose booster. This graph, courtesy of Dr Gerald Evans, shows that there is some protection from 2 doses (65% reduction in severe outcomes) and this increases to 81% reduction in severe outcomes with the booster!
D) For asymptomatic, staff who have been infected with COVID-19-When can I return to work at KHSC? You can return to work on Day 7 after 2 consecutive negative tests, and then you will be required to work following the KHSC Work Isolation policy. You will also need to use N95 until day 10 post exposure/infection.
For KHSC staff with a household positive contact who is asymptomatic (and not infected COVID-19 as evident from a negative PCR on day 4 post contact), they can return to work Day 5, with daily rapid testing and work isolation.
Stay well and keep the faith-we are going to emerge from this pandemic intact!