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March 27, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

As we move toward the day when there will be more COVID-19 cases in KHSC, I am confident in our people and our preparation. The team, broadly defined, is handling the stress admirably. Admittedly we all have our moments but the altruism and professionalism I have seen on the wards, in the clinics and in the offices is truly impressive. I want to give a special shout out to the medical residents, secretaries and administrative assistants in the Medicine program. We are so proud of your dedicated service. Also to the DOM administrative team-thank you for being truly #awesome.

Small acts of kindness help keep us connected despite physical distancing. Here are just a couple of examples. SEAMO sent care packages to our physicians-Thank you, SEAMO! 

gift bag for doctors

The DOM has done a scrub give away to our Women in Medicine. That said, most of the acts of kindness are just brief conversations or kind e-mails. It turns out our core values include not only provision of excellent care but also support for one another. 

Family concerns: Health care workers are concerned they will bring infections back to their family. COVID-19 infections are mostly community acquired-i.e. it’s more likely that a health care worker gets the infection from their family, rather than vice versa. Close family contacts are the highest risk of infection. Attack rates in family members are ~ 10%, much higher than with casual contacts. The majority of COVID-19 transmission in China is occurring within families. Of all of the infection clusters investigated, 78-85% were within families, with a household secondary attack rate of 3-10%. So doctors and nurses, be reassured. Wash your hands, change clothes when you come home from work and be reassured -you are not a vector!

Relieving anxiety: Don’t spend too much time on social media (or media in general)…the messages tend to bypass the cerebral cortex and land in one’s reptilian brain…prompting fear and anxiety. It’s a good time to exercise, read a book and e-connect with friends and family. Take in information in small doses from trusted sources.

Returning travellers: At 2pm today we all received the Emergency Alert below. Travelers returning to Ontario were reminded to self-isolate for 14 days-no visits to stores, families or friends!

emergency alert

COVID-19 101-what you should know about our foe: Here is some basic information on the COVID-19 epidemic. COVID-19 is a virus and infected patients may develop fever, cough, sore throat, headache and shortness of breath. There are few gastrointestinal symptoms. In most people the infection is mild and over 80% of infected patients recover without intervention. COVID-19 is readily transmissible. It has a reproductive number of 2.3 (although this varies by country. Higher reproductive numbers are worse. That means 1 infected patient leads to 2.3 other people getting infected. The good news is we can lower the reproductive number by hand washing, use of PPE and physical distancing. PPE use is important and has been discussed in my earlier messages. Despite the importance of PPE Hong Kong reported very little infection of health care workers (even amongst those who did not properly use PPE). Hospitals dealt with 42 confirmed cases of the coronavirus, no hospital-acquired infections occurred among healthcare workers in Hong Kong's public hospitals in the six weeks studied. Likewise in Singapore there was a case of exposure of 41 healthcare workers to an infected patient and even without PPE none of the exposed health care workers developed symptoms, and all PCR tests were negative. So remain calm and use PPE per KHSC guidelines, which are updated frequently.

COVID-19 infection is spread by large droplets from the upper airway when the patient coughs or sneezes. This means you largely get it by being within 3-4 feet of an infected person coughing or sneezing. The virus can survive on surfaces, which is why we ask that you wash your hands frequently, avoid touching your face and clean contact surfaces like counters and doorknobs; however this is not the main root of infection. It appears you can be infectious prior to the onset of clear symptoms or when you have mild symptoms (notably sore throats). Viral shedding is greatest in those who are most sick and lasts ~ 2 weeks, reflecting the period for which you can infect others. While the death rate from COVID-19 infection averages 2% (higher in the elderly, lower in the young) the deaths in COVID-19 patients often relate to their comorbidities (age, heart and lung diseases etc). There is currently no proven antiviral therapy. There are however clinical trials underway to test drugs like hydroxychloroquine, remdesivir, and kaletra. Lab tests (other than a COVID-19 PCR test and a d-dimer) are not helpful in making a diagnosis. There is currently no vaccine approved but several are in development.

Disease burden to date: There have to date been ~4000 cases in Canada with 39 deaths. There are 18 COVID-19 cases regionally, with several cases in health care workers. At KHSC we ran 76 tests for COVID-19 and 4 were positive, including 1 inpatient and 1 healthcare worker. Our regional sentinel surveillance testing reveals positive COVID-19 testing is still uncommon (~2% of tests). As long as it is <5% it is considered that there is not substantial community spread (although rates of positive testing are higher in nursing homes). Thus, we have a few more days in Kingston before will be significant community spread. In-hospital, random COVID-19 testing of asymptomatic people in Ontario still shows no positive tests. Once we reach a 10% rate of positive tests we will be broadening use of PPE, outside of Emergency Dept. In other words, if we had rates of COVID-19 like those in NYC, we would be masking everyone…but this is not the case and we believe we will not reach that level of infection.

A global perspective on COVID: If you want to follow the pandemic here is a useful site:https://www.worldometers.info/coronavirus/. The epidemic is largely resolved in China but is accelerating in the USA. This is a reminder of two things. China reminds us that the epidemic will likely last ~4 months, even with aggressive physical distancing and use of quarantines. The USA reminds us of the importance of public health measures being used uniformly and widely. Sadly on March 6, the US had the highest death rate — about 6% — among countries with more than 100 cases. Italy’s death rate is declining.

graph showing COVID-19 death rate for countries over 100

Hospital capacity update: The KGH census is 350 occupied beds, reflecting our hard work to make capacity for anticipated influx of COVID-19 patients (which is currently a trickle but will occur). Thanks Dr. Chris Smith, Mike McDonald, Michelle Matthews and the Medicine nursing leadership team for your stellar work in this regard! 

Discharge orders and transport instructions: We are developing COVID-19 admission and discharge order sets which will have input from IPAC and the Public Health department-stay tuned next week.

Incident Command Committee update: The response to the epidemic is being directed by this committee and they communicate in many ways, including through a daily ZOOM conference. Here are some highlights form today. 

  1. Some things at KGH have changed, most have not. Incident command has restricted building access, severely restricted visitors, provided clear guidance on the use of PPE and explained why we are conserving supplies (low incidence of infection and global scarcity of PPE), developed new code blue practices for cardiac arrest/resuscitation, and made their purchasing and payment practices more facile. Other than that there has been no change in our policies and procedures. There is no immediate plan for retired workforce to deliver frontline care.
  2. Fraud and cyber-attacks: Be care about emails from the outside. Be aware that there are increased attacks on KHSC staff because of the crisis, including outside emails requesting provision of data (don’t respond). If there is a question of possible suspicious emails please contact Ryan Hartman in KHSC IT.
  3. Supply and demand: Most masks and PPE pre pandemic were made in China and thus there is a global scarcity of these supplies. The KHSC policy is to buy PPE whenever and fromwherever they can. The problem is supply, not willingness to purchase. In this regard thank you to the many basic science research labs that have created an inventory of PPE for use if required by KHSC.

And with that, TGIF!

boy holding tgif sign

 

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