October 1, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
1) Health Canada has given the green light to a new rapid test for COVID-19
2) COVID volumes increase in KFL&A
3) COVID-19 volumes increase in Ontario with consistent reports of over 500 cases/day
4) Clarification of differences between KHSC and Queen’s University policies regarding what to do if you have been exposed to someone with symptoms of an upper respiratory tract infection:
5) There is not in fact a cap on testing numbers at Ontario’s community assessment centres
6) Global COVID-19 deaths exceeds 1 million
1) Health Canada has given the green light to a rapid test for COVID-19 Health Canada just approved the Abbott Diagnostics ID Now test, which can deliver results within 13 minutes of a patient being swabbed, without having to first send the specimen to a lab for processing. The government of Canada has signed an agreement with Abbott Rapid Diagnostics ULC to purchase up to 7.9 million ID NOW rapid point-of-care tests, pending Health Canada authorization of the tests (click here). ID NOW is a PCR-based system (like we use now) but uses isothermal technology, proprietary enzymes and constant temperature control to achieve rapid RNA amplification (click here).
For you science geeks-here is how it works (see Figure below).
However, it is not known when the new assays and the machines which run these point of care tests will actually be arrive in Canada. Also, while this type of testing is ideal to get a health care worker back to work rapidly or quickly clear a resident of a LTC facility there are limitations (beyond the relatively high cost of the assays compared with the current assay); namely the machines can only do 1 test at a time and ~ 3 tests per hour. Thus the assay is relevant for rapid determination of COVID-19 status but it likely will not solve our volume/capacity challenges. Currently the wait for results from community test facilities is too long (~ 4 days). The community testing is done in a network of provincial labs which handle specimens from around the province, not just locally. In contrast, the KHSC lab, which tests our regional patients, has a very rapid response time with results available for the inpatients usually within hours and always within a day. KUDOS team lab!
2) COVID volumes increase in KFL&A There have been 6 new COVID-19 cases in our region since my note on Monday. The total number of cases since the pandemic began is now 135. Currently there are 18 active cases locally and they are recovering in the community (see update from KFL&A Public Health). Several additional cases are under adjudication so this number may increase. As a result of the spike in cases we are now back in the yellow zone, after many months in green. The yellow zone is not as favorable as the green zone; but does reflect continued low community disease spread and indicates that we meet all the following criteria. There are no cases hospitalized in KHSC. We did 1843 COVID-19 tests at KHSC yesterday, with only 1 positive test (from Kawartha area).
3) COVID-19 volumes are increasing in Ontario with over 500 new cases/day (click here) COVID-19 cases numbers have doubled in Ontario ~ every 2 weeks. In the last 3 days on Ontario we have had over 500 case/day, with 538 cases today. 61% of all positive tests are currently in young adults or children; however, there is starting to be an increase in infection rate in middle age people.
Modeling suggests that the 2nd wave is about to intensify further. It is estimated that there may be 1000 cases/day by mid-October (click here).
Wave 2 is heating up. There has been a total of 52,248 cases, 5160 hospitalizations, and 2851 deaths in Ontario to date. The rate of positive SARS-CoV-2 tests is up at 1.5% yesterday. Ontario’s COVID-19 prevalence rate is 351.5/100,000, up significantly from a month ago, when it was 263.8/100,000. This provincial rate is 4X higher than in KFL&A, which has a prevalence of 62.5 cases/100,000 population. Toronto has a rate 9 times higher than Kingston (586.9 cases/100,000 population). The region with the highest prevalence of COVID-19 remains Windsor (624.2/100,000), largely because of a poorly regulated agricultural sector and suboptimal housing of farm workers.
An important difference between wave 2 and wave 1 is that, while cases are more prevalent in the past 2 weeks (see below), there have been no increases in death rates (thus far). However, we can now see that Ontario hospitalization rates are beginning to rise (click here) (extreme right of graph on left below-look at black line).
These graphs show that hospitalizations (black line below) are beginning to increase; as are ICU admission (green line bottom, right panel).
Most of the active cases in Ontario, per Ministry of Health data, are still in young people (< age 30 years-blue part of bar, left below). In terms of those under age 20 years (top bar), there is a lack of granular data; but based on low numbers in day care and elementary school children, I suspect most cases are in teens and young adults. We are starting to see increased infections in people ages 40-69 (click here) (note blue portion of bar reflects active cases).
Most active COVID-19 case in Ontario are in young adults but cases in older groups are starting to increase
Most active cases of COVID-19 are in Toronto, Peel and Ottawa (click here).
Our response to the second wave must include ongoing resilience, calmness and adherence to public health policies. As the pandemic progresses we may soon start to see more hospital admission and then an increase in mortality rates. This is not however an unavoidable problem. With careful attention to public health measures we can flatten the second wave without shutting down schools, business and society. To address wave 2 we should prioritize who we test and ensure rapid availability of test results. We need to limit indoor assembly to the permitted group size (<10). We should focus on key demographics who tend to get infected (young adults, migrant workers, low income neighbourhoods) and protect our health care workers (so they can protect society). We all need to continue practicing simple and effective public health measures (physical distancing, mask use indoors, frequent hand washing). However, we should not shut down schools and businesses. The unintended consequences of shutting down society for the 99.9% are huge and not readily reversible.
4) Clarification of differences between KHSC and Queen’s University policies regarding what to do if you have been exposed to someone with symptoms of an upper respiratory tract infection (URI): While many of us work in both institutions they are separate entities. The workers in a hospital setting are essential to provision of healthcare for people in South Eastern Ontario and we need our team to be on the premises whenever possible. Consequently, guided by IPAC (Infection Prevention and Control), led by Dr. Gerald Evans, we have developed a pragmatic policy for dealing with a very common problem-exposure to a person with URI symptoms. When we enter any KHSC facilities we are asked if we have been exposed to a person with a respiratory tract infection in the past 2 weeks. If we fail screening on this question we are directed to occupational health. Assuming we are deemed not to be an infectious risk (i.e. we are not febrile/coughing/sneezing etc.) we are then allowed to continue to work under a workplace isolation policy (which involves wearing appropriate PPE and self-monitoring). Please adhere to truthfully answering the screening questions! Without this practical policy we would struggle to staff the hospital. The policy has proved to be safe and we are not seeing cases of COVID-19 in the hospital, in part because most URI exposures of our staff and faculty are related to their own children, who have non-COVID-19 infections.
The Faculty of Health Sciences Policy (posted yesterday) is pasted below and is slightly different. Importantly it requires COVID-19 testing of the symptomatic contact be done before you can return to campus. While I cannot comment on the rationale for this, I will point out that most URI contacts are sick children and, as noted previously, they have extremely low risk of COVID-19 based on epidemiology to date. They are usually suffering from rhinovirus and other causes of childhood URIs. If your only symptomatic contact is a child with a runny nose and sneezing the vast majority of COVID-19 tests are negative. This mandatory testing accounts for the delay in testing for high risk individuals we are experiencing (delays both in getting the swab and more importantly in learning the results). Untargeted or poorly targeted testing in a system with finite testing capacity is part of the reason it now takes 4 days to get test results from community centers. Please respect and adhere to your employers requirements and recognize KHSC has a somewhat different policy than does Queen’s University.
5) Fake news-there is not a cap on testing numbers at Ontario’s community assessment centres: It is true that community assessment centers-must notify Ontario Health when they reach their target number of tests (click here); however, this is not a hard cap! The rumor of a testing cap resulted from a leaked memofrom Darryl Tooley, director of sub-region planning and integration with Ontario Health East, which called for "a pause in increasing testing capacity" in anticipation of growing demand caused by the second wave of COVID-19, coupled with the arrival of flu season.
This is not Ontario Health policy. The reality is we are doing and are allowed to exceed our target/project test volumes. Locally, we continue to exceed our community assessment centre target test volumes (400 cases/day) at Beechgrove. Nonetheless, Ontario is at or near its capacity for testing (currently ~40,000 tests per day in the public health labs). This is why the province is bringing pharmacies on board as community test centres and is looking forward to access to the new rapid testing assays mentioned previously. Going forward we will need to be wise about whom we test (i.e. not testing asymptomatic people). Hopefully, in the future, we can agree upon a more targeted approach to evaluate low risk groups, like toddlers who frequently have allergies and URIs but who rarely develop COVID-19.
KHSC capacity-preparing for an anticipated need for hospital admission: We have 62 ALC people and the hospital is quite full. We anticipate COVID-19 admissions in coming weeks and thus are focused on optimizing patient flow. By opening additional beds on Connell 3, one of our Medicine wards, we have been able to decrease congestion in the Emergency Department. That said, we are expecting COVID-19 admission and most of these patients are admitted to Medicine beds. Retaining capacity to rapidly deal with admission on the Medicine service will remain a priority.
COVID-19 in toddlers and young children: (click here).
There have been 233 COVID-19 cases in Ontario school students to date (up from 137 last week).
Amongst younger children and toddlers in Ontario’s 5,500 licensed child care centres and over 120 licensed home child care agencies there is also a very low COVID-19 burden (see table below). 79 children in Ontario’s licensed childcare facilities have been infected to date (up from 58 cases last week).
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.
Further reassurance for parents of young children comes from the graphs below which show rare hospitalizations and only 1 death to date in the pandemic. The rates of COVID-19 remain quite low in children (see below).
Beechgrove: Kingston’s community assessment center (click here):
The Beechgrove Complex lies just 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.
What Stays The Same
- Prior to visiting the Assessment Centre, patients and parents of young children are encouraged to complete an online self-assessmentto determine if they need to come in for a test.
- Walk-in patients will continue to be seen. Infants under 6 months of age should be taken to the Children’s Outpatient Centre at our HDH site or the Emergency Department for assessment.
- People are required to bring a valid Ontario health card or a piece of photo identification.
- People must wear a mask and maintain physical distancing at all times while in the walk-in line.
- Operating hours: Testing hours will return to 9 a.m. to 4 p.m. daily.
- Feedback tool: The public can now send their concerns, questions and comments to COVIDAC@kingstonhsc.caand every effort will be made to provide a response within two business days.
- A reminder: Ontario announced that we do not test asymptomatic people unless they have a confirmed COVID-19 contact.(click here).
The reforms required to make our Long term care facilities (LTC) safe are simple (but expensive): 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, deaths in nursing homes account for 66% of all deaths in Ontario, click here. This should cause policy makers to recognize that intervention needs to be focused on LTC facilities if we expect to reduce mortality. The reforms required to make our LTCs safe are simple (but expensive): single rooms for all residents, proper funding of PSWs so they only work at a single site, availability of COVID-19 testing for residents and staff and adequate supplies of proper PPE.
The rate of deaths from COVID-19 in Ontario has slowed in residents of Ontario LTCs with 6 deaths in the past weeks
17 or more neighbourhoods in Toronto have a COVID-19 prevalence of over 1000 cases/100,000 population (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 153 cases of COVID-19/100,000 residents whilst Weston has 2212 cases/100,000. These rates, both in low and high prevalence neighbourhoods, have increased each day for the past month. Half of Toronto’s neighbourhoods have a very high disease prevalence of over 1000 cases/100,000 population.
Canada’s second wave: We have had 159,296 cases of COVID-19 in Canada and 9300 deaths (see below) since the pandemic began. Most cases (86%) are resolved. However it is clear there are hot spots, like Ontario, Quebec and Winnipeg (see bottom left below). It is also clear we are well into a second wave (top right).
COVID-19 in Canada as of Oct 1st 2020.
COVID-19 testing: Ontario SARS-CoV-2 testing continues at a rate that exceeds the national average of 21.5%, with 27.4 % of Ontarians tested to date ( click here). Our overall positive test rate in Ontario still remains low (1.32%).
SARS-CoV2 Testing in Ontario as of Oct 1st 2020
American data of COVID-19 testing: In contrast with Canada’s 2.0% rate of positive tests, the USA has an average rate of positive COVID-19 tests of 4.7% (stable) (click here). The US-Canadian border will remain closed for routine travel at least until the end of October.
The COVID-19 global pandemic exceeds 1 million deaths and 34 million cases (a jump of almost a million cases this week): There are now 234,092,696 cases globally and there have been 1,016,050 deaths. The number of cases has doubled since July 27th 2020 when there were 16,296,635 cases globally. The pandemic hot spots are in the Americas (Brazil, Mexico, Peru, Chile and USA), India and Russia (click here). There are approximately 37 countries that have had a total of more than 100,000 cases. The USA with 7,252,701 cases and 207,331 deaths sadly tops the COVID-19 list and accounts for 21% of the global pandemic. India now has the second largest number of cases (see list of countries with the most cases below left). Here is a map of the pandemic as seen today:
A million global deaths have occurred since the pandemic began: Oct 1st 2020