May 25, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
COVID-19 Update: There is no change from Friday, meaning there are no new cases of COVID-19 in our region today (see update from KFL&A Public Health). The testing rate of positivity in KFL&A is 0.6% (vs 4.2% in Ontario). We did 573 tests SARS-CoV-2 on Friday and Saturday. There were 6 positive tests, 2 from the Kawartha area and 4 from Perth Smith Falls. There are also no new cases of COVID-19 in KGH although 4 people are being tested. The running total for the epidemic thus remains at 62 cases in the KFL&A region, with only 1 active, outpatient, case. Our PPE supply is stable with 3 weeks reserve, at the current level of activity.
Kingston remains in a bubble with a low incidence of COVID-19 (28.7 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). In contrast Toronto has a rate 10 times higher (297.2.1 cases/100,000 population). This is a reminder that the realities of, and response to, the pandemic will vary by location (see map below).
Care for the 99%
1) When will we ramp up elective care? (Answer: we still await Ontario Health’s permission). The first wave of ramp up (which we also await) has been focused on increasing elective procedures and surgeries. Once Ontario Health’s Directive 2 is lifted we are prepared to increase operating rooms at KGH and Hotel Dieu (to 9 and 5 rooms respectively) and to increase urgent endoscopy and cardiac catheterization volumes. We have modeled this to confirm that we have adequate PPE and bed capacity to deal with this increased case volume, while meeting the Ontario Health criteria for ramp up. We are now awaiting the Provincial and regional green light.
How’s the epidemic going? To date there have been 85,103 cases of COVID-19 and 6453 deaths in Canada (see below). There are currently 2395 hospitalized COVID-19 patients but only 339 patients (14%) are in intensive care units. The COVID-19 curve has flattened, with a decline in new daily cases per day. This improved epidemiology justifies the gradual reopening of the economy in many provinces, including Ontario.
The graph below shows that as the epidemic has evolved in Canada. The curve has flattened with fewer new cases per day (right upper and lower panels, below) and most cases no longer relate to foreign travel but instead to community spread (circle graph, right upper panel below). COVID-19 remains most prevalent in Quebec, particularly in Montreal, as you can see form the bar graph (below: lower left panel).
COVID-19 continues to disproportionately affect the elderly and particularly the frail and residents of 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 ~73% of all deaths from COVID-19!
Liberalized testing criteria for COVID-19
On Sunday Premiere Ford announced that anyone who is concerned about COVID-19 can be tested (click here). Ford said, “If you are worried you have COVID-19, or that you’ve been exposed to someone who has COVID-19, even if you’re not showing symptoms, please go get a test. You will not be turned away, you don’t need an appointment, just show up.”
What his announcement did not explain or turn into practical policy is:
- False positive tests: In asymptomatic people there are more false positive tests (i.e. your test comes back positive but you don’t have the disease). We have had 5 such false positives locally. A false positive test is usually suspected when only 1 of 2 genes for the virus is detected on the PCR assay OR if the test only becomes positive late in the run of PCR (beyond cycle 38). PCR is a test in which genes are amplified cycle by cycle and we run up to 40 cycles. At the extreme small errors become amplified exponentially (240 fold)…which is why late cycle “positives may not mean virus was actually present.
- False negative tests: At KHSC we have a great PCR diagnostic test-proven to separate the sick and the well 97% of the time…if you have symptoms at the time of testing! The negative predictive value the test is not so good if you don’t have symptoms. On average the negative predictive value of our test in an asymptomatic person is ~70% (meaning there remains more chance, up to 30%., that the test is negative but you could still be infected). This lower negative predictive value often leads to a call for test after test in a single individual. This reason for inferior test performance in healthy subjects relates in part to their lack of nasal mucus. It’s hard to get a reliable swab from a dry, healthy mucus membrane. This is quite different than when one is sick with an upper respiratory tract infection (not COVID-19). In this circumstances there are lots of nasal secretion and so we get good samples and if the PCR test is negative it reliably means you don’t have COVID-19.
- Logistics: Though Mr. Ford mentioned you will not be turned away he did not mention that you will likely be standing in a long line.
- Asymptomatic health care workers: The notion that health care workers can and should be tested repeatedly, even if asymptomatic, is not unreasonable. The idea is that any infection in this group could spread rapidly and impair function of the health care system. That said, there are important logistical issues that need to be dealt with. Where will this be done (at the hospital or at Memorial centre),? is this done on one’s own time? (likely yes if you’re not sick), what do we do if you test positive?, what is our capacity to run tests and will testing of asymptomatic health care workers slow assessment of subjects who are ill? At KHSC we are considering how to implement the provincial advice and turn it into policy and practice-stay tuned! Personally if you are asymptomatic I would wait a couple of days until we better understand how testing of asymptomatic people should be administered.
We have tested 4.1 % of all Canadians (1,522,947 people, see graphic below) and are at the same rate in Ontario (4.28%). As noted above, we now gearing up to do the expanded and recurrent viral PCR testing that is likely required to safely reopen Canada!
To see where Canada stands amongst nations in the COVID-19 pandemic, click here. The global case total has risen to 5,449,135 with 345,886 deaths. It is noteworthy that Brazil, which has a populist president with many similarities to Mr Trump, now is the 2nd leading country for COVID-19 globally, with 363,211 cases, closely followed by Mr. Putin’s Russia (353,427 cases). America still has more cases (1,647,741) than the next 9 most affect countries combined! The United States accounts for about 4.25% of the world's population, but currently has about 29% of the confirmed deaths from the disease, and models used by the White House suggest the tragic toll could rise to around 147,000 by early August.
The epidemiology seems to suggest that good governance might actually be an effective antiviral agent.
USA and Brazil and #1 and #2 in COVID-19 incidence
A revised reminder for people in the community
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 now 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. (last updated May 19th)
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.
2) Our hospitals and clinics are safe places to receive care (in part because everyone including staff is screened prior to entry and in part because the local incidence of COVID-19 remains low). You should not delay accessing care that you or your doctor deem to be urgent.
Staff screening and your badge: KHSC is moving this week to a more passive mode of screening (similar to that used by Customs Canada). Staff will answer a panel of questions related to COVID-19 risk. If all answers are “no”, you can proceed into the building. You will only be interacting with an in person screener if you answer YES to one of the COVID-19 questions. For this to work you must have a functional bar code on your badge. If your bar code doesn’t work you need to get a new badge at security, which is free). The program is being rolled out gradually across the hospital this week.
Expanded criteria for allowing a family visitor to support an inpatient at KHSC: Later this week (date to be determined) we will be slightly loosening visitor restrictions for in-patients. This change is anticipated to allow one, designated person to be a visitor/care partner. The designation of who can visit is not allowed to change during the patient’s stay (i.e. it will be the same person for each visit). The program will specify days for visits by floor. Stay tuned for details. Unfortunately, we are currently unable to relax the visitor/accompanying persons policy in the ambulatory environment and emergency department. The rationale for this is a lack of capacity for physical distancing in these venues.
The Department of Medicine completed a successful Food Drive for the Partner’s in Mission Foodbank in Kingston.
Here are Krista Knight and Karley Salsbury with some of the donations from folks across the DOM and KHSC! We also collected over $1600 in cash. KUDOS to you all!