November 5, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
1) Canada's top public health doctor now recommends 3-layer non-medical masks (click here)
2) KHSC capacity: Resuming elective admissions but beds are once again in short supply
3) New IPAC screening questions for patients and visitors
4) COVID-19 volumes remain stable in KFL&A (see update from KFL& A Public Health).
5) The second wave of COVID-19 accelerates in Ontario with our first day over 1000 new cases (click here)
6) Random acts of kindness: Sweet treats delivered to some of our nursing teams- by Medicine Residents and DOM faculty!
1) Canada's top public health doctor now recommends 3-layer non-medical masks (click here): Dr. Tan, Chief Public Health Officer and the Public Health Agency of Canada (PHAC) has changed their masking advice and now suggest that Canadians choose three-layer non-medical masks with a filter layer to prevent the spread of COVID-19. According to recently updated guidelines, homemade masks should now have a filter-type fabric, such as non-woven polypropylene fabric sandwiched between 2 layers of tightly woven fabric, such as cotton or line.
In addition, PHAC changed its guidelines to mention for the first time the possibility of aerosol spread of the virus. They state: "SARS-CoV-2, the virus that causes COVID-19, spreads from an infected person to others through respiratory droplets and aerosols created when an infected person coughs, sneezes, sings, shouts, or talks," (click here).
As discussed in prior notes we have always know that this was possible; however aerosolization still does not appear to be the major route of transmission (and there are huge PPE implications on the determination whether this form of transmission is probable (versus merely possible). If most transmission were by aerosol cloth masks would not work and we would all need N95 masks which filter out smaller particles. The data do not support this being the rule (or even being common). Rather most (but not all) COVID-19 cases appear to be spread by prolonged close contact implicating droplets as the vastly more common route of viral spread. Droplets are large particles that come from our mouth and nose and they fall to the ground courtesy of gravity within 3-4 feet. Conventional masks including cloth masks stop droplets. These mask are cheap to make, can be homemade and seem to be working. In contrasts, aerosol particles are much smaller and remain suspended in the air for many minutes, raising the possibility of infecting people who enter a space, even after the infected patient has departed. Stopping aerosol transmission requires N95 masks. In the hospital we use these more expensive and uncomfortable masks, but only where and when appropriate (i.e. with a known COVID-19 patient or during intubation).
We increasingly live in a polarized world and people hold opposing ideologies as pertains to masks. Some folks refuse to wear masks and confabulate stories suggesting that masks are dangerous; others are afraid to go to work and mask even when in private. The challenge in this lengthy pandemic is to accept that there is uncertainty, that knowledge and thus guidance changes over time and that possible and to remember that probable are two very different realties. It is possible you will win the lottery; but it is not probable. Thus when planning your finances one best not count on a lottery win!
I concede PHAC could do a MUCH better job communicating change (beginning by acknowledging a change has occurred and providing context). Also communicating the change might better be done by trained media folks . The use of the arts and humor, rather than blandly stating facts, might also help land the message. However, the facts are its good to wear a mask in public spaces when you can’t distance. As winter comes we will be more often in tight spaces in doors. My advice is to wear a mask in such circumstances. This could be a conventional clot mask, if that’s all you have. If you can procure a newer style cloth mask with a filter layer, even better. Despite the potential for aerosolization in certain circumstances in the community, I am not aware of any evidence supporting the superiority of N95 masks. If you are feeling the need to wear an N95 in a community setting you might first ask yourself, “Should I be meeting with this number of people in this space”. Distancing and outdoor spaces, as well has had washing and staying how when sick, remain key ways to slow the spread of COVID-19. For more on this read a recent article I published in The Conversation (click here).
For the meantime, despite acknowledging aerosol transmission is possible, PHAC’s advice to the Canadian public remains the same: Limit time spent in closed spaces, crowded places and close contact situations where there are "no controls, protocols or policies in place to reduce the risk of COVID-19, like good ventilation." PHAC also recommends maintaining physical distancing, hand-washing and mask-wearing.
2) KHSC capacity: Resuming elective admissions but beds are once again in short supply
Kingston General Hospital (KGH) is down to 61 beds compared with 90 available beds on Monday (although still better than the 38 available beds we had 2 weeks ago). Elective work has resumed. Not all of these beds are in locations that can accommodate an adult COVID-19 patient, however.
Elective clinical outpatient work continues. 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).
An added challenge in the past week was being so full we had to temporarily stop elective work and then this week we were victims of a cyberattack, which slowed communication. We need to be mindful that the system is under stress and try and interact with each other and with our patients recognizing the significant stresses in society and in the hospital (i.e. tread softly and read emails twice before sending). On the bright side, both elective admissions and elective clinic visits are available to us, so let’s make hay while the sun shines!
Use the Mobile Screening Tool: 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.
Screening staff will validate the confirmation at entry and you will be able to go directly to your appointment. This mobile screening must be completed a maximum of four hours before your appointment. If the screening confirmation expires, you will need to re-do the mobile screening or be screened in person (by a screener) when you arrive. With the exception of caregivers for children, this mobile screening tool is for patients only and does not give family members or caregivers an option to pre-screen because we must continue to restrict family presence for outpatients at KHSC in order to maintain physical distancing. To complete the mobile-screening in English, click here and in French, click here.
3) New IPAC-approved screening questions for patients and visitors at KHSC: These are the updated questions that all patients and visitors must answer before being allowed to come into the hospital and clinics. They questions have been altered to better reflect our improving knowledge of the disease, evolving epidemiology and improved understanding of disease time course and clinical manifestations. The changes are highlighted in red.
4) COVID-19 volumes remain stable in KFL&A: There has been 1 new COVID-19 cases in our region since my note on Monday. The total number of cases since the pandemic began is now 185. Currently there are 5 active cases locally. All local COVID-19 patients are recovering in the community (see update from KFL& A Public Health). There are no hospitalized patients at KGH.
5) The second wave of COVID-19 in Ontario now exceeds the 1st wave with positive test rate at new high of 4%:
A rising second wave of COVID-19 and an increase in hospitalization: Nov 5th 2020
There have been a of 80,690 cases, with 998 new cases since yesterday (click here). There have been with 6159 hospitalizations, and 3195 deaths in Ontario, since the pandemic began (up 7.6% and 4.0% since yesterday, respectively). The rate of positive SARS-CoV-2 tests in Ontario has increased to a new high of 4.0%!
Ontario’s provincial rate (542.8/100,000 population) has doubled in the past month and is now 6X higher than in KFL&A (84.6 cases/100,000 population). Toronto remains Ontario’s hotspot for COVID-19 (917.4 cases/100,000 population, up from 711 one week ago and 10 times higher than Kingston). Ottawa is also a hot spot at 693.7 cases/100,000 population (click here). Despite 3 weeks of increased provincial restrictions, wave 2 has not begun to plateau.
The majority of infections in Ontario are in young adults age 20-29. While most cases are in people under 60 years of age, almost all deaths are in people over the age 60 (click here). Deaths and hospitalizations have begun to increase in wave 2 -on right (See graph above).
What we should do in wave 2 of the COVID-19 pandemic. To address wave 2 we must acknowledge the one constant to our lives will be change. When and where the pandemic flares we will need to respond with local intensification of public health measures. This challenges us to think globally but act locally. We should:
- Use good public health practices: handwashing, physical distancing, use of masks in all indoor venues when physical distancing not possible
- Prioritize who we test and ensure rapid availability of test results. Turnaround times for COVID-19 test results that exceed 24 hours make case management difficult.
- Focus on testing and educating key demographics who tend to get infected (young adults, migrant workers, low income neighborhoods)
- Continue to respect our social bubbles and avoid socializing in large groups
- Protect our essential workers, including health care workers, so they can protect society).
- Fact check and have skepticism about media stories that offer sensationalistic perspectives, including new “miracle cures” or anti-public health policy rhetoric (e.g. the Great Barrington declaration-click here)
What we should not do in wave 2: We should not broadly shut down schools and businesses and this is not being proposed by public health or the government. The unintended consequences of shutting down society for the 99.9% are huge and not readily reversible (click here to read more on this topic). Rather, we need to manage outbreaks and hot spots with good public health policies, as are in place currently in KFL&A. This may involve intermittent closures of affected facilities and operations in affected regions; but should not require a general shut down of the economy at the level of the country, province or cities.
Neighborhoods, race and local variation in COVID-19: Half of Toronto’s neighbourhoods are COVID-19 hotspots with prevalence of over 1000 cases/100,000 population and Weston exceeds 3000 cases/100,000 (click here).
Toronto remains a collection of neighbourhoods with vastly different COVID-19 realities due to differences in social/economic, racial and health circumstances. For example, the Beaches has 274 cases of COVID-19/100,000 residents whilst Weston has 3246 cases/100,000, up dramatically from 2423 cases/100,000 1 week ago. However, when one examines new cases (i.e. what has happened in the past month since Oct 14th) case prevalence is of course lower-although still concerning-see graph below).
Case prevalence of COVID-19 in Toronto by neighbourhood: Oct 14th to present
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, as happened in Foothills hospital in Calgary and in Toronto. KHSC has a clear visitor policy, which has been in place for many months. All details on the policy can be found using this link (click here).
A reminder re: Community Assessment Center at Beechgrove-how to access and new access for staff and families: (click here): All COVID-19 test must be scheduled appointments (versus walk in). Appointments can be scheduled by telephone or by our new Eventbrite on line scheduling system. This is working well and we are doing 250 tests/day. In addition to this we are doing Queen’s testing and this volume is down too. This relates to more targeted testing guidelines form the province. Before booking a test, individuals should complete the online tool to determine whether they qualify for testing (click here). We are still working on our on-line system (it will be available shortly).
Per Ontario Health guidelines we do not test asymptomatic people unless they have a confirmed COVID-19 contact and we do not recommend testing children with runny noses as their sole symptom (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.
Testing for the community has been done at Beechgrove for many weeks now. This testing is running very smoothly because it is done by appointment and we have amazing staff . Consequently, we began testing staff at Beechgrove instead of Hotel Dieu to Beechgrove, effective Monday this week.
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 new program 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. Great job team KHSC!!!
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 1976 deaths in nursing homes (up 1959 on Monday) account for 61% of all deaths in Ontario, click here. In the last 3 weeks the rate of death amongst LTC residents has once again begun to increase and there are 3 local nursing home outbreaks (which is defined as a single case) including: Chartwell Wedgewood retirement center in Brockville (click here), the Fairmont nursing home (click here) and the Helen Henderson LTC (click here). A reminder-outbreaks in nursing homes start with a person in the community (health worker or family) acquiring the infection in the community and importing it into the facility. 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.
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 1435 up from 1238 on Monday and from 985 cases a week ago.
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 below). The rise in cases has been modest in these young children. 266 children have now been infected to date, up from 243 children on Monday and 209 cases 2 weeks ago.
Canada’s second wave of COVID-19: We have had 250,387 cases of COVID-19 in Canada and 10,377 deaths (see below) since the pandemic began. Canada is well into a second wave of COVID-19. Ontario remains the province with the highest amount of testing and A cumulative positive test rate of1.49%. However, the rate of positive tests in Ontario yesterday was ~4% (versus cumulative positive rate of 1.52%). Canada’s cumulative positive test rate is 2.29%. Note the increasing % of new cases in the bar graph on top left below and upward trend in new cases (orange line below).
COVID-19 in Canada Nov 5th 2020
The COVID-19 global pandemic exceeds 1.2 million deaths and over 48 million cases: There are now 48,344,880 cases globally and there have been 1,228,672 deaths. The number of cases has increased almost 3-fold since July 27th 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 9,516,261 cases and 234,011 deaths tops the COVID-19 list and accounts for ~20% of the global pandemic, while only accounting for ~4% of the world’s population. India has the second largest number of cases (see global map of COVID-19 Nov 5th-below).
6) Random acts of kindness
a)Trick or Treat- Medical Resident style: Medicine Residents delivered handwritten Halloween notes, like the one below, and sweet treats to the nursing and allied health staff. Thanks to our own Medicine Residents, Drs. Fiona Milne, Steph Chan, Sherwin Wong, and Grace Zhang, who took the lead in spreading a little joy. You elevated spirits (and possibly blood sugar) on our wards!
- b) Additional good news: Sweet treats delivered to some of our nursing and allied health teams from the Department of Medicine
Dr. Smith, Deputy Head of Medicine , Michelle Matthews, Program Medical Director of Medicine and I delivered some sweet treats to the nurses and allied staff on behalf of the 130 faculty physicians in the Department of Medicine. We appreciate our amazing colleagues, without whom patient care could not be provided. We know that it has been a stressful time for our nursing colleagues and we want you to know we are with you in spirit!