June 4, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
COVID-19 Update: There are no new cases of COVID-19 in the Frontenac Lennox and Addington (KFL&A) region (see update from KFL&A Public Health). There are no cases in KHSC. The running total for the epidemic remains at 63 COVID-19 cases in the KFL&A region and only 1 outpatient case is active. The positive test rate in KFL&A remains at 0.5% (vs 3.8% in Ontario), see below. Our PPE supply is stable with 3 weeks reserve, at the current level of activity.
Care of the 99%: Rational public health policy must consider all-cause mortality, not just death from COVID-19. I showed yesterday thatthere is a huge cost of care delayed, manifest as non-COVID-19 excess mortality. In an article today others sound the alarm and remind us of the link between physical and financial health.
Dr. Vivek Goel notes the inseparable consequences of the COVID-19 related slowing of health care and slowing of the economy. I like his quote: “So often the shutdown gets framed as a debate between health and the economy, but the economy is health, too.” (click here). He notes that unemployment increases the risk of death by 1.7% . Thinking of unemployment as a disease is an eye-opener. This is a real problem and is vast in its scope. 2.2 million Ontarians have been directly impacted by pandemic-related shutdowns through job losses (1.1 million), temporary layoffs or sharply reduced hours (1.1 million). Health Minister Christine Elliott acknowledged that about 35 Ontarians had died awaiting treatment for heart disease (estimates based on modelling). A staggering 52,000 hospital procedures had been cancelled or avoided as of April 22, and an estimated 12,200 more procedures are delayed each week we continue in our current mode, according to a recent article in the Star.
At KHSC we saw dips in stroke treatment in March and April. Stroke is a condition for which there is a great treatment (tissue plasminogen activator (tPA) and/or endovascular therapy (EVT)). However, time is of the essence and delays in care lead to death and permanent disability.
Data from Cally Martin and Dr AL Jin of our stroke program at KHSC. Note the decline in endovascular therapy and tPA treatment for stroke in March and April- Fortunately it looks like we were recovering our referrals and providing more therapy in May.
Our local experience reinforces the observations on delayed care in NY state, reported in the NEJM by Gogia et al (click here). They too found a decline in admission of heart attacks, stroke and cardiac arrest! These are not conditions that permit deferred care. The article notes that even as COVID-19 admissions decline in NYC cardiac the other patients are slow to return. Fear of the contagion likely drives system avoidance.
The ramp up in elective procedures is underway at KHSC, as I summarized yesterday. Patients are being required to self-isolate for 14 days prior to elective surgery-so planning and clear communication with the patient’s undergoing elective procedures is required. Meanwhile, Ontario Health has commissioned a committee to provide guidance on expanding ambulatory care; however, this process is slow. Ontario Health must develop a greater sense of urgency in rolling out its ambulatory care ramp up policy. People should not delay accessing care that they, or their doctor, deem to be urgent. If they are sick they can safely be seen in Emergency rooms, family medicine doctors’ offices and our clinics and hospital wards. Ethically we must provide equitable access to care for non-COVID-19 and COVID-19 patients! Dr. Goel’s article reminds us that we can’t separate physical and economic health, they are intrinsically linked.
Screening for out of province travel: All people entering the facility are asked if they have traveled out of province. If a health care worker answers “yes” to out of province travel during screening their risk of being infected is assessed by occupational health and their subsequent management is determined accordingly. If they traveled to low risk areas they will likely be allowed to return to work under conditions referred to as Work isolation. In such cases, the healthcare workers must wear a mask, monitor their temperature twice/day and self-isolate immediately if symptoms develop. This work isolation would last for 14 days, even if a SARS-CoV-2 test is negative. If a staff member has questions about this they should contact Occupational Health (ext 4389 at KGH site, or email COVIDrtwadjudication@kingstonhsc.ca). These policies are changing rapidly. I would strongly advocate for health care workers to avoid elective travel outside the province and, if they travel, return early enough that they can be evaluated/tested prior to returning to work. This is inconvenient; but there is not much about the pandemic that is convenient.
Will Toronto be next on the “no travel” list? Hard to say, but again, it would be prudent to avoid elective travel to Toronto until their COVID-19 incidence begins to decline. With a new academic year 140 medical residents and fellows are coming to town. My advice to them is to get to Kingston as early as possible, ideally 2 weeks in advance, to ensure they are not required to self-quarantine for 2 weeks.
COVID-19 screening of asymptomatic health care workers (policy in evolution). Currently testing of asymptomatic health care workers is voluntary and staff will be referred to the Memorial centre if they wish to be tested when they are asymptomatic. This testing is to be done on personal time, rather than during working hours.
Universal masking policy (local policy in evolution): Stay tuned for more on this!
How’s the epidemic going? To date there have been 93,441 cases of COVID-19 (~400 more than yesterday’s total) and 7543 deaths in Canada (see below). As you can see the number of daily reported cases continues to decrease (top right below) and the active case curve (orange, bottom right) has flattened. Almost all cases are in Quebec and Ontario, with Alberta being 3rd in case burden.
Flattening of Canada’s active cases curve (orange, right above)-the curve is not yet collapsing toward zero!
The disease remains most prevalent in Quebec (above, left). While the Ontario COVID-19 incidence curve has flattened this is not the goal. To declare an end to wave 1, we want it to actually collapse the curve (meaning daily new cases would have returned toward zero). Contrast the orange Ontario new case curve with a more desirable curve (orange), in this case from Manitoba.
Ontario June 4th
Manitoba June 4th
What’s happening in Toronto? Kingston remains in a bubble with a low incidence of COVID-19 (29.1 cases/100,000 population), positioning us to carefully reopen the city and ramp up activity at KHSC and Queen’s University (read the blog if you’re interested in hearing more re: Queen’s).
However, things are not so rosy in Toronto. In Ontario as a whole cases are up 1.2% from yesterday to a total of 29,403 cases since the pandemic began. Toronto has a rate >11 times higher (344.4 cases/100,000 population) than Kingston, and this rate continues to increase daily (see below). When it comes to travel in Ontario these data argue against elective visits to/from Toronto. While there are many other places on the map below that appear in red (>100 cases/100,000) the only city over 300 cases/100,000 is Toronto.
Residents of long term care facilities (LTC) (see today’s data below) continue to bear the brunt of the epidemic. The ~78,000 residents of Ontario’s LTC facilities account for less than 0.5% of the population but they account for ~71% of all deaths from COVID-19! There were 18 deaths since yesterday in Ontario LTCs.
Testing for SARS-CoV-2 (click here): We have tested ~5% of all Canadians (1,838,115 people) and are at a slightly higher same rate of testing in Ontario (5.43%).
Canadian testing for SARS-CoV-2 June 4th 2020
To see where Canada stands amongst nations in the COVID-19 pandemic, click here. The global case total is 6,551,290 and the number of deaths is up to 386,795. Here is a list of the most affected countries: USA, Brazil, Russia and UK. America remains in a league of its own (sadly), with 28.3% of all reported cases in the world!
America has 28.3% of all COVID-19 cases in the world (red dots)
A revised reminder for people in the community (last updated May 27th)
1) People in the community can self-refer for assessment and possible testing. We are now on testing people for much broader indications (we are no longer requiring fever or travel as preconditions for testing). We are testing people who have only 1 COVID-19-type symptom or who are concerned they have been exposed to the disease. KFL&A has also suggested that health care workers should be routinely and repeatedly surveyed by nasal swabs (discussed above). You can seek out testing at Memorial Centre in Kingston, (see instructions below). Here is a link to the self-assessment tool used to see if you should be tested (although I suspect it will be updated soon): click here.
The Community COVID-19 Assessment Centre is located at:
Kingston Memorial Centre (please use the well-marked main entrance)
303 York Street, Kingston, Ontario
Monday to Friday: 10:00 a.m. - 6:00 p.m.
Saturday and Sunday: 9:00 a.m. - 12:30 p.m.
In local news: Dr. Jane Philpott, the incoming Dean of the Faculty of Health Sciences and SEAMO CEO, has been appointed by the Conservative government of Ontario to lead the pandemic data effort (click here). She will be serving a 2 year term chairing a committee that will provide advice to Ontario Health Minister Christine Elliott and Treasury Board President Peter Bethlenfalvy. Dr. Philpott will take over from Dr Reznick as Dean on July 1st 2020.