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iceberg graph of global cases

October 26, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

headlines

1) SARS-CoV2 serology: Antibodies in the blood tell us case numbers are the tip of the iceberg (click here).)

2) COVID volumes remain in KFL&A community but we are surrounded by regions with rising COVID-19 prevalence (see update from KFL& A Public Health). 

3) The second wave of COVID-19 accelerates in Ontario with our first day over 1000 new cases (click here

4) Limited KHSC capacity: we have 490 patients and medicine and surgery beds are full and we are having staffing challenges.

1) SARS-CoV2 serology: Antibodies in the blood tell us that COVID-19 case numbers diagnosed by PCR swabs are the tip of the iceberg (click here). One thing that is clear with COVID-19 is that if you don’t test you won’t find cases. Another complexity is that the PCR testing of nasopharygeal swabs, the dominant form of testing used worldwide, only detects active infection. However, once a person recovers, this type of test becomes negative. Thus, these swabs are highly relevant to diagnose infected people and for contact tracing; however they miss a big group of people. We know that there are many people who have few symptoms when infected and may not present to be tested, particularly health young people. PCR testing capacity is also limited, another reason we underestimate the true COVID-19 burden. Enter the serosurvey, a test which measure the antibodies our bodies generate against the virus. These tests are not in widespread clinical use but they are excellent epidemiologic tools that tell us whether (not when) a person was infected with the virus. One caveat is that not every infection leads to production of antibodies.

I’m behind on reading the Economist (who isn’t) but their article on serosurveys from Sept 26-Oct 2nd (pg 21-24) merits review. The Economistsummarizes the finding of 279 serosurveys from 19 countries. They conclude that the true rate of infection (based on positive serology) far exceeds the rate based on detection of virus by the PCR test (implying substantial underdiagnosis). Based on serology the Economist infers that infections were already running at over 1million a day by the end of January—at a time when we were barely aware of this virus’ existence. By May, serology suggested a global rate over 5 million cases a day. As of their article being written serology would suggest that 500m-730m people worldwide had been infected (i.e. would have positive antibodies) vs the actual number of cases diagnosed by late Sept (~30 million people)-See graphic below:

graph and data in the shape of an iceberg

So many more people have antibodies than we know are infected??? As the kids say, “big if true”. The limited serology that is available would mean 6.4% to 9.3% of the world’s population had been infected prior to October. So is it true? Probably. While global data are messy because broad serologic testing is not being performed, there are interesting data on rates of infection vs rates of seropositivity form locales that have both pieces of data. Here is their data summary: “In Germany, where cases have been low and testing thorough, the seropositivity rate was 4.5 times the diagnosed rate in August. In Minnesota a survey carried out in July found a multiplier of seven. A survey completed on August 23rd found a 6.02% seropositivity rate in England, implying a multiplier of 12. A national serosurvey of India conducted from the middle of May to early June found that 0.73% were infected, suggesting a national total of 10m. The number of registered cases at that time was 226,713, giving a multiplier of 44. Such results suggest that a global multiplier of 20 or so is quite possible.” For those who are not number orient this means COVID-19 may be 1—20X as common as we realize.

If the virus is indeed causing many undiagnosed infections there is potential good and bad news. The good news would be that the advertised case fatality rates of ~5% would be an over estimate (i.e. most people are recovering without a diagnosis). Potential bad news could be that some people are dying from COVID-19 without a diagnosis! For example, The Economist has gathered all-cause mortality data from countries which report them weekly or monthly, a group which includes most of western Europe, some of Latin America, the United States, Russia and South Africa (see lower part of data panel). Between March and August these countries recorded 580,000 COVID-19 deaths versus a total of 900,000 excess deaths. They interpret this as meaning that the actual mortality from the pandemic was 55% greater than the official one (i.e. 900,000 excess deaths). In my view it is equally likely that the pandemic caused delays in health care for other conditions, like heart disease and cancer and that this accounts for the balance of the non-COVID-19 excess in mortality (click here).

graph showing deaths during the pandemic by country

What was the cause of the non-COVID-19 excess in mortality? Undiagnosed COVID-19 vs increased mortality due to delayed care for people with other diseases (heart disease and cancer for example).

2) COVID volumes stabilize in KFL&A: There have been 2 new COVID-19 cases in our region since my note last Thursday. The total number of cases since the pandemic began is now 176. Currently there are 6 active cases locally (down from 7 cases last Thursday). All local COVID-19 patients are recovering in the community (see update from KFL& A Public Health). There are no hospitalized patients at KGH. The KHSC lab did 1621 tests over the last 4 days; 11 were positive. Tow of these positive tests were from KFL&A. As good as things are in KFL&A we are surrounded by regions with rising rates of COVID-19 infection. This is highly relevant, since we are the tertiary care medical center for Hastings-Prince Edward County and Leeds, Grenville and Lanark County. 

kfl&a stats for covid-19

5) The second wave of COVID-19 in Ontario now exceeds the 1st wave There have been a total of 71,224 diagnosed cases since the pandemic reached Ontario. On Sunday we had our first day with more than 1000 new cases (click here)! There have been with 5822 hospitalizations, and 3091 deaths in Ontario, since the pandemic began (up 29 deaths from last Thursday). Hospitalization rates continue to increase and are up 8.2% since yesterday (28 new hospitalizations). The rate of positive SARS-CoV-2 tests in Ontario has just up-ticked to a very concerning rate of 3.8%! Ontario’s COVID-19 prevalence rate is 479.2 /100,000 population (click here). A month ago, between wave 1 and 2 it was 263.8/100,000. 

This provincial rate is 5X higher than in KFL&A, which increased slightly since Monday to 79.4 cases/100,000 population. Toronto remains Ontario’s hotspot for COVID-19 (808.9 cases/100,000 population, up from 711 one week ago), a rate 10 times higher than Kingston (82.3/100,000). Windsor (655.6 cases/100,000 population) no longer has the highest prevalence of COVID-19 having been surpassed by Toronto. Ottawa is also a hot spot at 627.4 cases/100,000 population (click here)

The majority of infections in Ontario are in young adults age 20-29. While most cases are in people under 60 year of age, almost all deaths are in people over the age of 60 years (click here). There is a sustained rise in hospitalizations in Ontario in the past 2-3 weeks (shown by the black line in the graph below), although this has plateaued. At the peak in May, Ontario had just over 1000 hospitalizations/day whilst currently we have 278 hospitalized people (unchanged since last Monday (See below). For some reason the rate of hospitalization and case fatality rate is lower in wave 2 (thus far).

graph showing hospitalized cases

Hospitalization rate during the COVID-19 pandemic

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:

  1. Use good public health practices: handwashing, physical distancing, use of masks in all indoor venues when physical distancing not possible
  2. 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.
  3. Focus on testing and educating key demographics who tend to get infected (young adults, migrant workers, low income neighbourhoods) 
  4. Continue to respect our social bubbles and avoid socializing in large groups
  5. Protect our essential workers, including health care workers, so they can protect society). 
  6. 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, as discussed last Thursday)

What we should not do in wave 2: 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 (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.

4) Limited KHSC capacity: A need to put a temporary hold on elective admissions.

Kingston General Hospital (KGH) is almost full (meaning elective work is on hold at KHSC and elective admission must be temporarily curtailed). It is noteworthy we have 5 people being tested to exclude COVID-19. Should they test positive we will need to reactivate our COVID-19 ward (Connell 3). We have substantial ventilator capacity.

khsc bed and ventilator capacity

Unfortunately there are no beds available in medicine or surgery following a very busy weekend of admission. In addition, we have shortages in nursing staff and other staff, despite aggressive attempts to recruit new staff and offers of overtime to existing staff. There is just simply a shortage of healthcare staff to recruit in the province of Ontario. After conferring with hospital leadership, I'm asking each attending physician/ faculty member to temporarily pause elective admissions. A similar request is being made to our surgical colleagues. I know it is a very difficult choice to determine whose elective care can be delayed; but this is the reality that currently faces us. This is NOT advice to patients: Patients should see their doctors and continue to seek healthcare as needed.

Meanwhile, KHSC is pursuing solutions that may assist our bed crunch, including: a) deciding how best to move people that have ALC status from our hospital (either to home or to more appropriate locations), b) activation of new beds in the Hotel Dieu site and c) having frank conversations with partner hospitals in southeastern Ontario to ensure cases are distributed appropriately. KGH has a short-term capacity issue that is likely exacerbated by the fall season, which always has a high bed census. 

I have had to ask faculty to triage admissions to temporarily delay elective admissions (i.e. identify people whose inpatient procedure/care can wait several weeks). I do this reluctantly and only out of recognition that we must preserve some Medicine bed and Emergency Department capacity. Elective clinical outpatient work will continue for now.

I will have more information about the short-term bed capacity by Thursdays note.

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.

screenshot of tweet of pre screening tool on an iPhone

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.

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). 

Community Assessment Center at Beechgrove: (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).

photo of female getting covid-19 testing nasal swab

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.

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. 

photo of two young boys in a classroom

Children are usually infected by an adult, usually in their home, rather than by other children. That said, the number of cases in school age children (which includes teenagers) has increased to 985 from 920 cases last Thursday. 

photo of a 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 below). The rise in cases has been modest in these young children. With 209 children in Ontario’s licensed childcare facilities infected to date (up from 204 cases last Thursday).

The reforms required to make our Long term care facilities (LTC) safer are simple and cannot accidently incarcerate LTC residents: 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 1921 deaths in nursing homes (up 11 from last Thursday) account for 63% 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. There is a new outbreak with 1 infected resident at the Chartwell Wedgewood retirement center in Brockville (click here), following an earlier outbreak at the Fairmont nursing home last week (click here). The definition of an “outbreak” in a nursing home is quite strict and only requires 1 case to qualify as an outbreak.

current table of cases in LTC

LTC deaths in Ontario up to Oct 25th, 2020

COVID-19 Hotspots in Toronto:

toronto skyline with CN tower

More than half of Toronto’s neighbourhoods are COVID-19 hotspots with 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 236 cases of COVID-19/100,000 residents whilst Weston has 2423 cases/100,000 (see map below). Rates in both in low and high prevalence neighbourhoods, have increased each day for the past month, although these rates have peaked compared to last week. Nonetheless, more than half of Toronto’s neighbourhoods have a very high disease prevalence of over 1000 cases/100,000 population (each dot is a neighbourhood on the map below and all dots to the right of the one highlighted (New Toronto) have >1000 cases/100,000 population). 

graphs showing cases in Toronto by date and age

Toronto pandemic Oct 26th 2002:Not the size of the second wave -top graph and that the infection is most common in young adults (bottom bar graph-on left).

Canada’s second wave of COVID-19: We have had 217,763 cases of COVID-19 in Canada and 9962 deaths (see below) since the pandemic began. It is clear the country is well into a second wave of COVID-19, which exceeds the first wave in terms of case number (top graph) but not yet in numbers of hospitalizations. There are increasingly more active cases (orange in bar graphs bottom left). The most often infected people are young adults (bar graph on right).

graphs of Canada cases and deaths by date, province and age

COVID-19 in Canada as of Oct 22nd 2020.

Manitoba has the highest rate of new cases per capita in Canada and this threatens the stability of health care in this province.

graph of current covid data in Manitoba

COVID-19 in Manitoba Oct 26th 2020

COVID-19 testing: Ontario SARS-CoV-2 testing continues at a rate that exceeds the national average of 26.2%, with 33.1 % of Ontarians tested to date ( click here). Our overall positive test rate in Ontario still remains low since the beginning of the pandemic (1.4%) vs 2.14%. Another important caveat to our relatively favorable test positive rate is that in some areas, such as certain neighbourhoods in Toronto, positive test rates exceed 10%. This is areminder COVID-19 is global but its impact varies greatly even from one neighbourhood to the next.

map of Ontarioand graph showing total cases vs testing vs positives

COVID-19 testing in Ontario Oct 26th 2020

The COVID-19 global pandemic exceeds 1 million deaths and over 43 million cases (up 1 million from Monday!): There are now 43,238,481 cases globally and there have been 1,156,212 deaths. The number of cases has increased 2.6-fold since July 27th 2020 when there were 16,296,635 cases globally. The pandemic hot spots are in the USA, India, Brazil, and Russia ( (click here). There are approximately 40 countries that have had a total of more than 100,000 cases. Below I show a list of countries with more than 200,000 cases. The USA with 8,661,917 cases and 225,379 deaths tops the COVID-19 list and accounts for ~20% of the global pandemic. India has the second largest number of cases and is poised to overtake the USA soon. A global snapshot of COVID-19 for Oct 26th is shown below.

world map and ranking of cases/deaths by country

COVID-19 cases globally Oct 26th 2020

Stay well!

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