July 13, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
Local COVID-19 Update KFL&A:
The local outbreak of COVID-19, largely related to infections acquired in nail salons, is under control. There have been no new cases over the weekend. Our local epidemiology is consistent with the gradual improvement in the epidemic we are seeing across Canada and in Ontario. The running total for the epidemic remains at 105 cases in the KFL&A region (see update from KFL&A Public Health) (Table below). The table below is a reminder where the case have occurred in our region and shows (in the bottom bar graph) and shows the rise and fall of cases related to the nail salon related outbreak (yellow bar graph). There are now only 12 active cases and these COVID-19 patients actively recovering in the community. There are no longer any inpatients with COVID-19 in KHSC. There are no inpatients with COVID-19 in KHSC.
SARS-CoV-2 Testing: Over the past 3 days we have performed 1337 SARS-CoV-2 tests. There were only 4 positive tests. One positive was a retest of a known patient from KFL&A and the other 3 were from the Kawartha area. Our test positivity rate in KFL&A continues to fall and is currently <0.4%.
This is overall good news and should allow us to continue our surgical ramp-up and resume our ambulatory care ramp up, as we continue efforts to provide better care of the 99.9% (click here for more on this). KHSC has capacity for our elective procedure ramp up; but one risk to this capacity is the resurgence of Alternate Level of Care (ALC) inpatient people. We had reached a low of 20 ALC people and are now back up to a census of 40 people (who should not be in hospital by definition). This puts our capacity to provide care for the 99.9% in jeopardy.
In addition, we need to adhere to universal masking in KHSC and public masking in indoor spaces (at Queen’s University and in all places of business in our region). The virus is circulating in the community and maintaining physical distancing and hand washing (plus masking in indoor spaces) will remain important for some time to come required.
Where are we with drug therapy and vaccines for COVID-19:
Image source and related story (click here)
A brief summary of COVID-19 therapeutics is posted below. If you want an even briefer summary we have 2 drugs which have modest benefits, Remdesivir, an antiviral agent, and dexamethasone, a steroid which reduces inflammation. Vaccines are in human clinical trials.
For the longer version click here (and read on)
NIH Guidelines recommend dexamethasone 6mg per day for up to 10 days in hospitalized COVID-19 patients who are mechanically ventilated or who require supplemental oxygen. Preliminary results from the UK RECOVERY trial showed Dexamethasone 6 mg once daily, taken orally or by injection for 10 days reduced the 28 day mortality rate by 17% with a highly significant trend showing greatest benefit among patients needing ventilation. Mahase E. Covid-19: Low dose steroid cuts death in ventilated patients by one third, trial finds. BMJ. 2020;369:m2422. [PMID:32546467]
⇒Remdesivir: This is an antiviral that is somewhat effective against SARS-CoV-2. NIH Guidelines recommend remdesivir in hospitalized patients with an oxygen saturation < 94% on ambient air or who require mechanical ventilation, ECMO or supplemental oxygen. Preliminary results of an NIH-sponsored randomized clinical trial (ACTT; NCT04280705) published in NEJM showed remdesivir accelerated recovery from advanced COVID-19: (reducing median time to recovery from 15 to 11 days) with a statistically insignificant trend toward reduced mortality. There was no difference in effects between 5 vs 10 days of therapy. Goldman JD, Lye DCB, Hui DS, et al. Remdesivir for 5 or 10 Days in Patients with Severe Covid-19. N Engl J Med. 2020. [PMID:32459919]
⇒Hydroxychloroquine (HCQ): This is an antinflammatory drug with some antiviral effects. NIH Guidelines recommend against use of chloroquine or hydroxychloroquine for the treatment of COVID-19, except in a clinical trial (click here).
Here is why HCQ is not recommended thus far:
o UK RECOVERY trial: HCQ treatment arm stopped after preliminary analysis showed HCQ did not reduce mortality or improve other outcomes in hospitalized COVID-19 patients.
o NEJM reported a randomized trial showing HCQ did not prevent COVID-19 infection when used as post exposure prophylaxis within 4 days after exposure.
o Observational study published in JAMA showed amongst 1,438 hospitalized COVID-19 patients those receiving HCQ, azithromycin, or both had no significant differences in mortality from those not receiving these drugs.
o Observational study published in NEJM showed HCQ not associated with either a greatly lowered or an increased risk of the composite end point of intubation or death.
⇒Interferon beta-1b, lopinavir–ritonavir, and ribavirin. This is a trial of an immunomodulator (interferon) + antiviral agents. The combination was reported in an open label, randomized trial (NCT04276688) to be safe and superior to lopinavir–ritonavir alone in alleviating symptoms and shortening hospital stay and viral shedding in patients with mild to moderate COVID-19. Hung IF, Lung KC, Tso EY, et al. Triple combination of interferon beta-1b, lopinavir-ritonavir, and ribavirin in the treatment of patients admitted to hospital with COVID-19: an open-label, randomised, phase 2 trial. Lancet. 2020. [PMID:32401715]
New Version of Universal Masking Policy Starts Tomorrow:
Beginning on Tuesday, all people entering the hospital will be required to wear a mask. MASKS WILL BE PROVIDED AT ALL KHSC ENTRY POINTS and they must be used (unless an exemption has been prospectively obtained). All staff will be provided with a mask for “entry/exit” of KHSC. This mask must be worn to enter the building. These masks can and should be reused for a week (storing it in a paper bag when not in use-bag provided). For staff in non-clinical areas this is the only mask you need. However, for staff in clinical areas you need to pick up a new masks at the care desk in the clinic and on wards. Clinical staff will then switch back to wear their “entry/exit” masks when they leave the building. Occupational health will be reviewing requests for exemption. When there is an exemption, it will usually mean that a face shield will be worn as an alternative (i.e. some form of facial PPE will still be required). An important reminder that face shields are not equivalent to mask (i.e. not as effective) and exemptions will likely be rare.
Fake News in the Kingston Area Targeting Our Children: “Hugs Over Masks”
Mr. Trump has finally put on a mask to the relief of virtually all rationale people. Canadians like to think we are above the fray and are immune to fake news and irrational ideas: We are not! Read about how sticky false ideas, called cognogens, are (click here). Here is an anecdote that I want to bring to your attention regarding an organization that is disseminating false information in the community. They are called Hugs Over Masks and their misguided message confuses civil liberties with the benefits of using masks in indoor public spaces as a way to combat the pandemic. Masks are safe and we as physicians have used them for a century! Sadly with advances in social media and color printer technology, anyone, not matter how ill-informed can make a credible looking website or brochure. One of my colleagues passed this information on to me. Their child and another child, who was wearing a face mask, were approached by an adult and handed this pamphlet. The adult who gave them the brochure indicated this was for them and they needed to read it (because they were wearing a mask). This incident is concerning because although its contents are false and dangerous the style of the brochure appears professional (see below). It will be important to keep track of this and be aware that such ideology exists. This is there website (link) which I offer only to indicate that I consider this disinformation dangerous and something you may wish to discuss with your kids so they are forewarned.
Leon’s Centre testing facility is open for COVID-19 testing of community members (click here for details of hours). The wait time at Leon's Centre is short (10 minutes).
QUEEN’S employees – For those who went to the specific locations notified by KFL&A and have to test/self-isolate: Please contact Ms. Anita Ng, DOM Manager, in order to complete a Queen’s self-isolation form
Symptomatic KHSC staff: Should KHSC staff develop symptoms consistent with COVID-19, please contact occupational health and safety and they will tell you how to proceed (ext 4389 at KGH site, or email COVIDrtwadjudication@kingstonhsc.ca). You will likely be tested at the Hotel Dieu testing centre. Do not come to work!
Kingston’s COVID-19 outbreak (click here) Ontario’s prevalence rate is 247.1/100,000, much higher than in KFL&A, at 49.4 cases/100,000 population. Toronto still has a rate >8 times higher (437.1 cases/100,000 population). The prevalence in Toronto has increased every day for the past month, reflecting neighbourhood hot spots. Males account for16,946 confirmed cases (46.1%) and below age 80 years men (blue) have an excess mortality rate (although this reverses over age 80 with female predominance). Note one again the absence of mortality in children.
Provincially the epidemic is in modest decline. There were 129 new cases yesterday (up 0.4% from yesterday). Ontario has had a total of and 36,723 total cases and 2719 deaths to date. The 0.7% rate of positive SARS-CoV-2 tests yesterday was the lowest rate to date and continues a week of daily decline.
The prevalence of cases in Toronto is still increasing daily due to over a dozen neighbourhoods which are COVID-19 hotspots, defined as rates over 1000 case/100,000 (click here), including: Moss Park, Newton Brook West, Yorkdale Glen-Park, Downsview Roding CFB, Maple Leaf, Rexdale-Kipling, Black Creek, Mount Olive, Beechborough, York University Heights, Mount Dennis, Glenfield Jane Heights, and Weston. Humber Heights Westmount with 1763 cases/100,000 once again has the highest prevalence in Toronto. The ministry has deployed public health experts, mobile testing facilities and contact tracers to deal with these “epidemics within epidemics”.
Nonetheless, things are improving in Toronto as you can see from their dashboard (click here).
COVID-19 in Toronto
How’s Canada’s epidemic going? We have had 107,589 cases of COVID-19 in Canada and 8783 deaths (see below). As seen below, most cases are resolved (89%, green, top left). The number of active cases per day has plateaued (orange bar graph, below right and orange line graph, bottom right). Quebec remains the hot spot with the majority of Canada’s active cases and more active cases than the rest of the country combined.
Canadian aggregate data
The epicentre for COVID-19 mortality remains our long term care facilities (LTC) (see today’s data below). The ~78,000 residents of Ontario’s LTC facilities account for less than 0.5% of the population but they still account for 68% of all deaths from COVID-19! There have been 1836 deaths to date. There were 2 deaths since yesterday in Ontario LTC centres. Canada had the highest rates of mortality in LTCs of any survey country. 81% of all COVID-19 deaths occurred in residents of LTCs (click here)! This is sad, embarrassing and requires rapid change in how we license, fund and monitor LTCs.
Testing for SARS-CoV-2 (click here): We have tested 9.05% of all Canadians (3,471,604 people). As expected with increased testing of less symptomatic people the rate of test positivity is declining and nationally is 3.1% (vs 2.17% in Ontario). Ontario SARS-CoV-2 testing (see below) continues at a rate that exceeds the national average, with a rate of 11.6.
The COVID-19 pandemic gone up by more than a million cases in the past week. There are now 12,934,317 cases globally and 569,697 deaths. The pandemic hot spots are in the Americas (Brazil and USA), Russia, and India (click here). These 4 countries account for half the world’s cases.
Global trends: Globally the pandemic is increasing (click here), see bar graph below. This is due in large part to failed leadership and the related growth of the epidemic in Brazil and the USA.
A reminder that visitors accompanying a patient to clinic should be kept to a minimum and if authorized they should be preapproved and identified with the screeners: As you are aware, we are still restricting family members from attending at the HDH site due to physical distancing challenges as we work to add clinical services back in that were paused earlier this spring. The exception for patients is where they absolutely must have a caregiver attend in order for us to provide safe care. Examples of this include people with dementia, very elderly/frail, those who are confused (e.g. neurological issues such as post-stroke).
In other circumstances (e.g. a patient would like their family member to hear a diagnosis, instructions or be part of the appointment), we encourage them to use their cell phone and put their loved one on speaker phone during the appt instead. Screeners have begun this week to track those patients who believe they have been told to bring a family member with them to compare with the list of formally approved exceptions in order to try to understand and prevent miscommunication or delays. In these cases, patients and/or their family members were insistent that they were told to bring someone, but screeners did not have this patient on our exceptions list.
To my physician colleagues: Please use good judgement and try and limit accompanying people at in person visits and when they are necessary let screeners know in advance.