June 9, 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 cases in the KFL&A region and all are resolved. The positive test rate in KFL&A remains at 0.5% for the 13,111 tests performed to date (vs 3.6% positive in Ontario).
The impact of nonpharmacologic interventions: A paper in the journal Nature this week (click here) estimates that nonpharmacologic interventions by 6 countries reduced their net confirmed cases by 62 million, with most of the benefit deriving from interventions in China and South Korea. This study used each country’s epidemic characteristics, prior to implementation of a policy change, to estimate the difference between the observed magnitude of the epidemic and what would have happened if the policy had not been implemented and had the COVID-19 curve continued its initial vector (i.e. no flattening). The type of nonpharmacologic interventions deployed varied by country but included 1) travel restrictions, (2) social distancing through cancellations of events and suspensions of educational/commercial/religious activities, (3) quarantines and lockdowns, and (4) additional policies such as emergency declarations and expansions of paid sick leave. Canada has implemented many similar policy changes. The authors estimate “ that there would be roughly 465 X the observed number of confirmed cases in China, 17 X in Italy, and 14 X in the US by the end of our sample if large-scale anti-contagion policies had not been deployed.”(see graph below).
In this same vein, here is an interesting article from the New York Times, that I was given by Dr. Kathie Doliszny (click here). They surveyed 511 epidemiologist and asked them “when they expect to resume 20 activities of daily life, assuming that the pandemic and the public health response to it unfold as they expect.” They answered based on their knowledge, personal biases and publicly available COVID-19 epidemiology data.
Don’t tell my wife (Dr. Doliszny, herself an epidemiologist) but I disagree with the conservative response of those surveyed. Only 46% would attend a small dinner party within the next year! I myself would be more open to the invite, with certain provisos.
Life is a risk benefit exercise. The risk from COVID-19 for most healthy people is mild-moderate (80% become minimally symptomatic) and that risk can be reduced by physical distancing, hand hygiene and avoidance of sick contacts, which need to continue. In contrast the risk of prolonged social isolation, unemployment and the related psychosocial issues is real and growing. We will all need to work hard to retain our civility as we deal with friends, families and colleagues who each have their own threshold for reopening society and more fully reengaging in social activities. I think the planned Phase 2 activation of Ontario business this Friday (summarized below) strikes a good balance (Phase 2 reopening of Ontario-click here).
Effective Friday, June 12, 2020 at 12:01 a.m., the province will increase the limit on social gatherings from five to 10 people across the province, regardless of whether a region has moved to Stage 2. Additionally, all places of worship in Ontario will also be permitted to open with physical distancing in place and attendance limited to no more than 30 per cent of the building capacity to ensure the safety of worshippers. "The health and long-term economic well-being of the people of Ontario has guided every decision we have made in response to COVID-19," said Rod Phillips, Minister of Finance and Chair of the Ontario Jobs and Recovery Committee. "The people and employers of Ontario have demonstrated responsible behaviour throughout the global pandemic. I'm confident that will continue in Stage 2 and beyond. Our collective health and the economic recovery of the province depend on it."
Below are the number of cases (from yesterday) by province.
COVID-19 in Canada June 8th 2020 (click here) (DAY OLD DATA)
The epidemic in 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 (373.9 cases/100,000 population) than Kingston (29.1 cases/100,000), and this rate continues to increase daily (click here).
Travel outside Ontario-is our policy aligned with other centres? (quick answer, basically yes): Currently, 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) 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. This policy will likely change as we enter into Phase 2 of reopening the province assuming there is not a rebound in case number. Our local policy is not the case at every hospital in Ontario. Indeed in some systems, like the Ottawa hospital system, might not be able to have such a policy since many of their workers live in Quebec. However, when I discussed this with Dr. Evans, who is our IPAC lead and guru on all things COVID-19, he reminded me that Ottawa hospitals have a universal masking policy in place, so they are essentially doing what we are doing (except that we are masking staff selectively). Moreover, if Ontario Health does not accept KHSC’s argument for a regional approach to universal masking this will a moot point, since we all will be wearing masks each day-stay tuned on this issue.
The epicentre for COVID-19 mortality remains 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 were 18 deaths since yesterday in Ontario LTCs.
Testing for SARS-CoV-2 (click here): We have tested ~5.42% of all Canadians (2,009,988 people) and are at a slightly higher rate of testing in Ontario (6.08 %). This map (from yesterday) shows the testing by Province (click here)
To see where Canada stands amongst nations in the COVID-19 pandemic, click here. The global case total is 7,164,393 and the number of death is up to 407,393. Here is a list of the most affected countries: USA, Brazil, Russia and UK. America with 1,965,685 cases has the same number of cases as Brazil, Russia UK, India and Spain combined.
This high US prevalence has major ramifications for opening of the US-Canadian border. Prime Minister Trudeau announced today that Canada is allowing “Immediate family members” defined as spouses, common-law partners, dependent children and their children, parents and legal guardians to enter Canada form the US. (Click here).
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.
Pharmacists in the pandemic: yesterday’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 1-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.