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June 8, 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) and no COVID-19 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. We did over a thousand tests this weekend. There were 4 positive tests, one from the Kawartha area, one from Perth Smith Falls and one from Belleville. The positive test rate in KFL&A remains at 0.5% (vs 3.6% in Ontario).

chart of COVID-19 cases in KFL&A

Our PPE supply is stable with 3 weeks reserve, at the current level of activity. However, we are awaiting a decision from the province re: our request to implement a locally customized version of Ontario Health’s proposal that hospitals adopt a universal masking policy. Our local epidemiology supports our current policy; however, we are prepared with a plan to alter our masking policy, should we be required to do so. We will announce the KHSC plan soon.

Care of the 99%-the ramp up in care provision begins: We have some additional good news on the subject of the ramp up of elective care services. To get permission to ramp up, KHSC must continue to attest to the Ministry of Health that we have reserve capacity to deal with a second peak in COVID-19 (meaning adequate supplies, beds, staff etc.) and that we can ramp down, within a week if required. With these provisos, we have been given the green light to ramp up elective surgery, cardiology and endoscopy procedures. As of today, KHSC gone to “green” on the renal transplant program, meaning that we can return to performing renal transplantation at baseline rates (~2 cases/month). This is a small but very important program. Soon we hope to begin our outpatient ramp up from the current state (which is only 33% of our baseline of 1700 visits/day at Hotel Dieu) to ~50% of prior capacity (which would mean 800+ visits/day). It is important to note that neither of the imminent procedural or ambulatory ramp up plans returns us to full capacity-that is a for a later stage in the recovery of our health care system. Still phase one ramp up is good news!

How’s the epidemic going? To date there have been 95,699 cases of COVID-19 and 7,800 deaths in Canada (see below). As you can see the number of daily reported cases continues to decrease (bottom right below).

map of Canada and the prevalence of COVID-19 cases

Just the facts: COVID-19 remains most prevalent in Quebec. Some readers have been sensitive to my reporting of Quebec numbers but epidemiology cannot be filtered through provincial affinities or other non-fact based views. There is no intended blame on my part in reporting the scope of the epidemic in one part of the country or another. Moreover, the reason for a local increase in incidence needs to be studied, with the goal of understanding, not blaming. Local epidemiology is critical in local decision making, whether the locale is Toronto, Montreal or Kingston. It’s not enough to report on the outbreak for the city as a whole, since neighbourhoods within the city, particularly those with high rates of poverty, can have many fold higher rates of COVID-19 than adjacent wealthy neighbourhoods. That said, Quebec with 22% of the population has 55% of all cases and Montreal itself has had 26,205 cases to date with 83 new cases on Sunday (click here). That means 27% of the entire epidemic resides in one Canadian city.

Map of Montreal showing areas of COVID-19

Montreal epidemiology

How do Québec and Montreal compare to the next most affected sites in Canada, Toronto and Ontario?(click here). While the Ontario COVID-19 incidence curve has flattened we need it to actually collapse (meaning daily new cases would have returned toward zero). As I pointed out on Friday, the Ontario epidemic is intimately related to the continued persistence of the outbreak in Toronto. Toronto has a rate 12 times higher (370.3 cases/100,000 population) than Kingston (29.1 cases/100,000), and this rate continues to increase daily (click here).

cases in Toronto

Ontario epidemiology

Toronto itself has hotspots, neighbourhoods where COVID-19 is much more prevalent. Just as there is no room for provincialism or nationalism in the management of COVID-19, there is no role for sensitivity about neighbourhood epidemiology. We need to identify where the disease is afoot and then focus our efforts in these areas. The map of Toronto (below) shows the diversity in the impact of COVID-19, which tends to correlate with the socioeconomic status of the neighbourhoods, as is true for most illnesses. We need to better deploy resources to microregions which are disproportionately affected and the provincial government will need to develop a nuanced, regional approach to the epidemic, which is a challenge for a large bureaucracy.

map of Toronto area showing neighbourhood covid-19 prevalence

COVID-19-a reality that varies by neighbourhood within Toronto

One misconception I would like to address relates to what happens when a health care worker declares they have traveled our of the 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 prior to travel. Please note that most workers who have traveled out of province and return with no illness and no contacts with sick individuals will not be precluded from working in KHSC. 

Another inconvenient truth of this pandemic is that the epicentre is within 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 account for ~71% of all deaths from COVID-19! There was 1 death since yesterday in Ontario LTCs.

Cases of COVID-19 in LTC since Jan

Testing for SARS-CoV-2 (click here): We have tested ~5.33% of all Canadians (1,980,922 people) and are at a slightly higher rate of testing in Ontario (5.99%).

graph showing COVID-19 testing vs positives in Ontario

To see where Canada stands amongst nations in the COVID-19 pandemicclick here. The global case total is 7,036,623 and the number of death is up to 403,211. Here is a list of the most affected countries: USA, Brazil, Russia and UK. America has the same number of cases as Brazil, Russia UK, India and Spain combined. Some question whether these countries are as good at reporting the disease as the USA (i.e. is this an exaggerated difference related to better case counting in the USA). It’s hard to know; however, these are the data we have at present. Nonetheless, the USA has ~28% of all reported cases in the world at yet accounts for only 4% of the world’s population! This has major ramifications for opening of the US-Canadian border.

list of countries ranked by COVID-19 deaths

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, (303 York Street, Kingston, Monday to Friday: 10:00 a.m. - 6:00 p.m., Saturday/Sunday: 9:00 am-12:30 pm). 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.

alarm clock with smiley face

Pharmacists in the pandemic: Today’s blog (click here) features the amazing work pharmacists have done to keep our drug supply stable during the pandemic. It also explains why pharmacies have only been able to prescribe a one month supply of a medication and why patients may have experienced increased dispensing fees. These issues are resolving/resolved now but relate to Canada’ tenuous drug supply chain.

Stay well!

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