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November 23, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

Headlines


1) Kingston moving into the yellow zone at midnight tonight (click here).

2) Ontario crosses 100,000 case threshold with 12,918 active case in Ontario and a 3.7% hospitalization rate (click here): 

3) COVID-19 volumes stable in KFL&A (click here): see thank you to KFL&A Public Health Case and Contact tracing and School teams at end of note

4) Canada’s second wave of COVID-19: Over 330,000 total cases and a rapid spike in infection in western Canada:

5) The COVID-19 global pandemic exceeds 1.3 million deaths and over 56 million cases (up 2 million from Thursday) (click here):

6) South Dakota provides further evidence that public health measures work (by failing to institute them and seeing a 50% positive test rate and surge in deaths, click here):

Regular reminders and updates:

  • KHSC bed capacity: 
  • Use the Mobile Screening Tool to expedite clinic visits 
  • KHSC visitor policy: 
  • COVID-19 testing at Beechgrove Community Assessment Center: (click here): 
  • Increased outbreaks and deaths in Long Term Care facilities (LTC)
  • COVID-19 in toddlers and young children: (click here). 

1) Kingston moves into the yellow zone at midnight tonight (click here).

The Ontario government is moving Kingston from Green to Yellow status tonight. Dr. Kieran Moore is quoted as saying that Kingston meets the threshold for the new restrictions (> 10 cases per 100,000 people) justifying the change in status. A particular focus is the restaurant industry. KFL&A has seen15 cases of COVID-19 linked to fast food establishments over a two-week period. The Yellow status is not a lockdown but will mean that:

  • Fines can more readily be handed out for public health rule violations.
  • Recreation programs will be limited to 10 people indoors and 25 people outside
  • Personal care service businesses will need to obtain contact information from all patrons
  • Restaurants and bars must stop serving alcohol at 11 p.m. and close at midnight, establishments must collect contact information for customers, and limit the volume of music. 
  • A maximum of six people will be permitted to sit together indoors
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KFL&A was previously “Green,” which meant only standard public health measures (physical distancing, indoor masking, staying home when sick, hand washing) were required. The upgrade to “Yellow” adds to these measures and authorizes enhanced targeted enforcement, fines and enhanced education to limit further transmission in the region (click here). The restriction under Yellow status are mild compared to the Red level lockdowns that are occurring in Toronto and Peel, where many businesses that are deemed non-essential will be closed to indoor service.

Mayor Steve Ferguson, in Prince Edward County, released a statement on Saturday urging all residents to avoid travelling to red zones and for visitors to stay away. The issue of travel to hot spots is challenging because we are all so connected. It is interesting to reflect that Kingston is Picton’s nearest “hot spot”, while Toronto and Ottawa are ours.

These are very challenging times, but there is finally realistic hope of the pandemic ending in the not too distant future, with the arrival of vaccines in the spring. Meanwhile we need to buckle down and protect ourselves. Limiting travel to and from areas with a higher rate of infection (no travel to red zones is ideal) is wise. Read item 6, about South Dakota, which serves as a warning that we ignore public health rules at our own peril.

2) Ontario’s crosses 100,000 case threshold with 12,918 active case in Ontario and a 3.7% hospitalization rate (click here): 

table of cases since Jan 15 2020 in Ontario

Ontario’s pandemic at a glance

There were 1589 new cases today, up +1.4% from yesterday (click here).Our 7-day case average is 1429 new cases/day. There have been 6847 hospitalizations, and 3451 deaths in Ontario, since the pandemic began (up 6.8% and 3.4% since yesterday, respectively). The rate of positive SARS-CoV-2 tests in Ontario remains high at 4.6% today (although this is down from a peak of 5% ~2 weeks ago). 

Thus the pandemic is not currently well controlled with 12,918 active case in Ontario today. 

Ontario’s provincial rate (678.1 /100,000 population) has doubled in the past month and is now 6X higher than in KFL&A (108.1 cases/100,000 population). Peel (on Toronto’s western border) is the hot spot in Ontario with 1292.3 cases/ 100,000 population. Toronto’s prevalence remains high at (1122.9 cases/100,000 population, up from 711 cases/100,000 population 2-weeks ago and ~10 times higher than Kingston) (see map below). Ottawa is also a hot spot at 768.2 cases/100,000 population (click here).

map of Ontario showing prevalence of covid -19 by colour

COVID-19 prevalence by region in Ontario, Nov 23rd 2020

The second wave of COVID-19 exceeds that seen in wave 1 (see graph below).

graph of active cases hospitalized and in icu

Deaths and hospitalizations are increasing in wave 2 (See graph above). There are 484 (black line) hospitalized people out of 12,918 active cases (red bars), a hospitalization rate of 3.7%.

The distribution of cases continues to be highest in young adults (age 20-29) and the elderly (see graph below). There is similar incidence in males and females, except in those over 90 where we are seeing female predominance. However, most deaths are still in people over the age 60, see graph below (click here).

graph showing cases by age

Neighbourhood variation in COVID-19 in Toronto: Half of Toronto’s neighbourhoods are COVID-19 hotspots and have a cumulative prevalence of over 1000 cases/100,000 population (click here).

Toronto skylines with CN tower

Toronto remains a collection of neighbourhoods with vastly different COVID-19 realities due to differences in social/economic, racial and health circumstances. Although COVID-19 is increasing in the city as a whole, case load is very high in some Toronto neighbourhoods. For example, Maple Leaf (highlighted on the map below) has had 3798 cases/100,000 residents, roughly 12X the burden of COVID-19 in the more affluent Beaches neighbourhood (301 cases of COVID-19/100,000 residents). 

map of Toronto area

When one examines recent cases (i.e. those diagnosed since Oct 30th), case prevalence is lower-although still concerning-ranging from 22 cases/100,000 residents, in Palmerstown-Little Italy versus 1157 cases/100,000 residents, in Maple Leaf. 

3) COVID-19 volumes have increased in KFL&A: There have been 18 new cases in the region since my note on Monday. The total number of cases since the pandemic began is now 233, up 1 case since Thursday. Currently there are 24 active cases in KFL&A, down 7 from Thursday. Counting the adjacent counties there are 54 active cases in southeastern Ontario. All local COVID-19 patients are recovering in the community (see update from KFL& A Public Health). In the past 4 days we have done 2243 COVID-19 tests with 6 positive tests (1 from Kingston, 4 from Kawartha area, and 1 from a provincial nursing home). There have been 3 outbreaks in KFL&A including in 4 cases (one in a school, one in a business and one in a nursing home). Almost all local cases of COVID-19 have some connection to contact with people from Toronto or travel to Toronto. Caution should be used in considering travel to and from Toronto/Peel.

table of current kfl&A data

Outbreaks cases in KFL&A by date as of Nov23rd 2020

4) Canada’s second wave of COVID-19: Over 330,000 total cases and a rapid spike in infection in western Canada: We have had 330,503 cases of COVID-19 in Canada and 11,455 deaths (see below) since the pandemic began. There are 54,449 active cases in Canada today, up over 652 from yesterday. Most cases of COVID-19 in Canada have been (in descending order), in Quebec, Ontario, Alberta and BC. 16.7% of all cases are now active cases. Canada has done over 12.1 million tests and has a cumulative test rate positivity (since the pandemic began) of 2.57%.

several graphs of covid-19 data in Canada

COVID-19 in Canada Nov 23rd 2020

Ontario remains the province with the highest amount of testing (see bar graph top left above) and has a cumulative positive test rate of 1.76%, although it is much higher lately (4.6%). Rates of infection are rapidly rising in all Western provinces (BC to Manitoba) whereas they are rising more slowly) in Quebec and Ontario. Rates of new infection are low in all Maritime provinces. There are new outbreaks in the North in indigenous communities in Nunavut (click here) and on Hudson Bay. Here is what is happening in Alberta. Note the very concerning rise in hospitalizations and the fact 19% of hospitalized patients are in intensive care units.

graph of covid data in Alberta

COVID-19’s aggressive second wave in Alberta is leading to many hospitalizations

5) The COVID-19 global pandemic exceeds 1.3 million deaths and almost 59 million cases (up 2 million from Thursday) (click here): There are now 58,766,731 cases globally and there have been 1,390,003 deaths. The number of cases has increased over 3-fold the beginning of August, 2020 when there were 16,296,790 cases globally. The pandemic hot spots are in the USA, India, Brazil, and Russia (click here). The USA with 12,249,575 cases and 256,798 deaths tops the COVID-19 list and accounts for ~21% of the global pandemic, while the USA only accounts for ~4% of the world’s population. India has the second largest number of cases (see global map of COVID-19 Nov 23rd-below). 

global map and ranking of countries with covid

6) South Dakota provides further evidence that public health measures work (by failing to institute them and seeing a 50% positive test rate and surge in deaths (click here): In contrast with Ontario’s ~3.4% rate of positive tests, the USA has an average rate of positive COVID-19 tests of 9.8% (a dramatic rise from October but unchanged from last week) (click here). However, positive rates of testing are a staggering 44.9% in South Dakota (versus just over 11.3% in Illinois, 8.1% in Florida, and 9.5% in New Jersey).

picture of sinking ship with the word mistakesgraph of covid data in South Dakota

South Dakota surges with half of all COVID-19 tests returning positive!

If you don’t believe in the effectiveness of masks and public health measures, consider the case of south Dakota, which is led by a Republican governor, Kristi Noem, who, like the US president, is a denier of all things scientific. Here is a quote from a CNN article (click here): “Deaths from Covid-19 have surged 74% in just the last two weeks. Forbes just called South Dakota one of the 10 riskiest states in the country to visit. And how is Kristi Noem, the state's Republican governor, reacting to all of this? "It's a good day for freedom," her office said in a statement Friday. "Joe Biden realizes that the president doesn't have the authority to institute a mask mandate. For that matter, neither does Governor Noem, which is why she has provided her citizens with the full scope of the science and trusted them to make the best decisions for themselves and their loved-ones."  This governor’s decision (or more accurately her lack of a decision) resonates with (whether or not its based on) the highly flawed. Libertarian, Great Barrington declaration (click here).

screenshot of the governor of South Dakota Kristi Noem

The US-Canadian border will remain closed for routine travel at least until the end of November (click here).

signs at the USA Canadian Border

Regular reminders

KHSC bed capacity: Resuming elective admissions but beds remain in short supply

Kingston General Hospital (KGH) has 88 beds available, down from Thursday (when it was 96 beds). Not all of these beds are in locations that can accommodate an adult COVID-19 patient, however. Elective inpatient care continues; but with the rising wave of COVID-19 in Ontario it is uncertain how long this can be sustained. I urge colleagues to see patients in person that require face to face visits (it remains safe to do so). When in person visits are not possible, we offer video visits (using REACTS and OTN), telephone visits and e-consults (using our asynchronous, online consultation for family doctors). While both elective admissions and elective clinic visits are available to us, let’s make hay while the sun shines! 

animated photo of hay field with sunshine rays

Use the Mobile Screening Tool to expedite clinic visits: Complete the COVID-19 pre-screening tool here and you will be able to “skip the line”: One way to safely expedite entry of patients into our facilities is to have all patients complete our pre-screening questionnaire before their clinic visit. This will screen out people who are sick and expedite entry to the facility for everyone. Reducing lines waiting to enter the clinics will be particularly important as colder weather arrives. The mobile screening tool only takes a few minutes to complete and you will receive an email with confirmation to bring with you, along with your appointment slip, in printed form or on your mobile device. To complete the mobile-screening in English, click here and in French, click here.

screenshot of KHSC mobile prescreening app

KHSC visitor policy: One of the hardest aspects of COVID-19 care in the hospital is the need to restrict visitors to ensure we don’t import COVID-19 into the hospital. A very few cases of COVID-19 can paralyze the hospital, particularly if they are brought in by visitors and then spread undetected. All details on the policy can be found using this link (click here). 

COVID-19 testing at Beechgrove Community Assessment Center: (click here): All COVID-19 test must be scheduled appointments (versus walk in). Our online system, Coconut, launched today and will assist in contact tracing. Appointments can be scheduled by telephone or by our new Eventbrite on line scheduling system. Before booking a test, individuals should complete the online tool to determine whether they qualify for testing (click here). The Beechgrove Complex is south of the King St. West/Portsmouth Avenue intersection. Signage will direct people through the Complex to the Recreation Centre building at 51 Heakes Lane for walk-in testing. Operating hours: Testing hours will return to 9 a.m. to 4 p.m. daily. To be tested you will require: A valid Ontario health card or a piece of photo identification. You must also wear a mask and maintain physical distancing at all times while in the walk-in line.

animated picture of a nasal swab test for covid-19three young boys dressed up as doctors

Because health care workers (doctors and staff) are increasingly having to miss work because their children have been sent home from school or daycare with symptoms of a upper respiratory tract infection, we have arranged that their children can access expedited testing at Beechgrove . The goal of this service is simply to allow the healthcare worker to return to work as quickly as possible for the public good. The children of staff will be tested between 1230 -1300 by appointment, 7 days/week. The new program for families applies to children up to age 18, an includes children of staff and physicians who provide clinical care and service. Staff and physicians themselves should contact occupational health to book their testing appointment. To book an appointment for a child, KHSC staff should call 613-548-2376. Testing of clinical staff and faculty and their children is processed at the KHSC lab with an average turnaround time of less than 24 hours.

Increased outbreaks and deaths in Long Term Care facilities (LTC): We have 4060 LTC beds in KFL&A. As discussed in many prior notes, most COVID-19 deaths occur in people who are not only old but who are also frail and live in nursing homes and long term care facilities (LTC). As of today, the 2141 deaths in nursing homes (up 26 cases from Thursday) account for 62.0% of all deaths in Ontario, click here.

table with LTC covid-19 data

In the last 3 weeks the rate of death amongst LTC residents continues to increase daily! Outbreaks in nursing homes usually start with a person in the community (health worker or family) acquiring the infection and importing it into the facility. Thus, protecting LTCs is best done with a combination of reducing community spread of COVID-19 and ensuring single occupancy rooms in LTCs (as well as appropriate pay for PWS workers, provision of PPE and rapid testing capacity).

COVID-19 in toddlers and young children: (click here). 

Fortunately kids remain much less likely to be infected by SARS-CoV2 and when they are infected they usually become much less ill (click here). The vast majority of upper respiratory tract infections in kids in Ontario are caused by other viruses, like rhinovirus and RSV. Thus, health policy makers and parents of young children should recognize that while children are not immune from COVID-19 infection, infections are relatively uncommon and outcomes are usually excellent for those who are infected. Nonetheless, we are about to prioritize children of healthcare workers for testing at KHSC so we can return the parents to work when children with symptoms (which will rarely prove to be COVID-19) are sent home from school or daycare.

two school aged boys in a classroom

Children are usually infected by an adult, usually in their home, rather than by other children. The number of cases in school age children (which includes teenagers) has increased to 2209 up from 2147 cases on Thursday and more than double the number from 3 weeks ago (985 cases). 

female toddler holding an apple

Amongst younger children and toddlers COVID-19 remains relatively rare. In Ontario’s 5,500 licensed child care centres and over 120 licensed home child care agencies there is a very low COVID-19 burden (see table ). The rise in cases has been modest in these young children. 357 toddler age children have now been infected to date, up from 353 cases on Thursday and 209 cases 3 weeks ago.

A big thank you: We need to commend the KFL&A Public Health Case and Contact tracing and School teams for keeping this latest COVID-19 blip under control. In coordination with our community testing facility, which performed 350+ COVID-19 tests per day for a week, they have managed to stem the spread of cases that might otherwise have resulted from outbreaks in one of our schools and in several fast food restaurants! KUDOS!!!

Stay well!

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