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Neon #Awesome

October 8, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

headlines

1) COVID volumes continue to increase in KFL&A related to a Queen’s University student cluster 

2) The second wave of COVID-19 in Ontario now exceeds the 1st wave (click here

3) Advice on what self-isolation means for people (click here)

4) Improved time to receive results of a COVID-19 test at Beechgrove following change in provincial testing criteria for children (click here): 

5) Reduced KHSC capacity: The challenge of ALC people occupying beds and the need to retain bed capacity for an anticipated surge in COVID-19 admissions

1) COVID volumes continue to increase in KFL&A related to a community cluster at Queen’s University: There have been 8 new COVID-19 cases in our region since my note on Monday. The total number of cases since the pandemic began is now 156. Currently there are 21 active cases locally (down significantly from last week as cases resolve). All cases are recovering in the community (see update from KFL&A Public Health). Almost all cases continue to be Queen’s University students, most of whom are connected by virtue of having attended a party together. Thus while the province is in a second wave, locally we are more accurately characterized as being back where we were with the Binh’s nail salon cluster. There are no cases hospitalized in KHSC. Hastings county has 8 active cases and Lanark county has 9 cases. As in the rest of the province the most infected population demographic are young adults age 20-29 with a female preponderance. We did 2192 COVID-19 tests in the past 2 days at KHSC, with only 2 positive tests from KFL&A.

graph of latest covid-19 cases in KFL&A

The latest COVID-19 cluster in KFL&A has raised case count but not increased hospitalizations

2) The second wave of COVID-19 in Ontario now exceeds the 1st wave, with 583 new cases yesterday (click hereCOVID-19 cases have doubled in Ontario ~ every 2 weeks. Modeling suggests that there may be 1000 cases/day by mid-October (click here). The graph below shows wave 2 has surpassed wave 1 (top left) and that deaths are once again beginning to increase (bottom right). Deaths are primarily occurring in Toronto.

4 graphs showing covid-19 stats since jan

As in previous notes we see the virus is primarily infecting young adults (blue part of bars on graph below) but is causing mortality (gray part of bars in graph below) in older adults, as was the case in wave 1.

bar chart showing active, resolved and deaths by age

Finally, note the concerning, recent rise in hospitalizations in Ontario (shown by the black line in the graph below on left for ward admission and green line on right graph for ICU admission).

2 graphs comparing active and hospitalized vs hospitalized and in icu

There have been a total of 55,945 cases, 5205 hospitalizations (an almost 10% increase compared to last week), and 2988 deaths in Ontario, since the pandemic began. The ICU admission rate is also beginning to rise. 1109 COVD-19 patients have been in ICU since the pandemic began and this rate rose 2 % recently. The rate of positive SARS-CoV-2 tests increased to 1.9% yesterday.

Ontario’s COVID-19 prevalence rate is 376.4/100,000, up more than a 100 cases/100,000 since July, when it was 263.8/100,000. This provincial rate is 4X higher than in KFL&A, which has a prevalence of 72.4 cases/100,000 population. Toronto has a rate ~9 times higher than Kingston (633.8 cases/100,000 population). Windsor still has the highest prevalence of COVID-19 (628.7/100,000), largely because of a poorly regulated agricultural sector and suboptimal housing of farm workers (click here).

Ontario map highlighting areas of high covid-19 prevalence

Most active cases of COVID-19 are in Toronto, Peel, Ottawa, and York (click here), see graph below.

bar graph ranking most active cases of covid-19 by city in Ontario

Location of cases in Ontario Oct 8th (click here)

Strategy for the second wave must include ongoing resilience, calmness and adherence to public health policies. 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.

3) Advice on what self-isolation means for lay people (click here) (from an article by Steph Crozier in the Whig Standard today): As physicians we often are asked whether someone needs to self-isolate. Customizing the advice on whether and how to “self-isolate” depends on many factors. Has the individual been exposed to someone with an undiagnosed upper respiratory tract infection (URI), have they been exposed to a person infected with COVID-19?  What is their living situation? When giving advice the answer is often dependent on the particular scenario. 

Here are some examples taken from an article in the Whig Standard today, quoting Dr. Kieran Moore local medical officer of health for KFL&A.

Self-isolation if you have been infected with COVID-19: Self-isolating means the infected person cannot leave their home or host visitors. The person should arrange to have groceries and other necessities delivered to them. A person who tests positive for COVID-19 now only has to isolate for 10 days rather than 14. Leaving isolation assumes the person has become asymptomatic by 10 days.

Self-isolation: for homeless people: According to public health, if a person who is required to isolate is homeless, they will be given accommodations in an isolation facility.

Self-isolation if you have URI symptoms and are waiting you COVID-19 test results: These individuals should self-isolate until they receive a negative result and are symptom-free for 24 hours. Working while sick was never a great idea but is not acceptable in the COVID-19 era. Our policy at KHSC is that if you are have become symptomatic and have a negative test you can return to work under a rigorous workplace isolation policy.

Self-isolation if you are a close contact of a positive COVID-19 case. You have to isolate for 14 days from the last exposure to the positive case, regardless of your test result.

People entering Canada from out of the country: You are still required to isolate for 14 days upon their arrival, per the federal Quarantine Act.

You do not have to self-isolate if:You are the family or roommate of an asymptomatic person who is a close contact of a positive case.

Violation of the isolation rules can lead to substantial fines, under the Health Protection and Promotion Act ($5,000 per day for individuals and $25,000 per day for Corporations). Exceptions to these rules exist, most notably 

  1. for those providing an essential service
  2. a person receiving an essential medical service or treatment; 
  3. Dr. Moore decides a person’s isolation would not be in the public’s interest.

4) Improved time to receive results of a COVID-19 test at Beechgrove following change in provincial testing criteria for children (click here): 

Testing volumes are down significantly since the province mandated that we no longer tests children with the isolated symptom of a runny noses in absence of COVID-19 symptoms like cough and fever or exposure to a positive case. Our community test volumes promptly plummeted from >500 tests/day to ~216 tests/day. As a result, test results are now getting back to people within 2 days (a drop form 4 day waits just last week)! This shows the importance of strategic and targeted testing with the goal on ensuring rapid return of results. 

Beechgrove: Kingston’s community assessment center (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.

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).

A reminder: The ministry announced that 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 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. We do not have drive through testing yet but are considering this possibility. 

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.ca.

Requirements

  • 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.

5) Reduced KHSC capacity: The hospital is quite full and becoming fuller by the week. We have >60 ALC people in hospital (and as a reminder these are people awaiting placement who do not require medical care and should not be admitted to hospital). We anticipate COVID-19 admissions in coming weeks and thus are focused on optimizing patient flow. By opening additional beds on Connell 3, our COVID-19 response ward, we have been able to decrease congestion in the Emergency Department. However, since patients admitted usually are cared from on Medicine wards, mainly Connell 3 our COVID-19 ward, retaining capacity to rapidly deal with admission on the Medicine service will remain a priority. As you can see below, our KGH reserve capacity for a COVID-19 surge is reduced with 50 available beds, down from 62 earlier in week. We do still have good ventilator capacity. In the event of a COVID-19 hospitalization surge and/or quarantine of wards we will need to expeditiously transfer ALC people form the institution to more appropriate sites.

bed management at KHSC

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. Children are usually infected by an adult, usually in their home, rather than by other children. Here are some data supporting this assertion, first for school age children and then for daycare age children.

photo of 2 boys in school classroomchart of cases in school aged children

There have been 453 COVID-19 cases in Ontario school students to date (up from 262 cases on Monday).

photo of young female toddler

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). 126 children in Ontario’s licensed childcare facilities have been infected to date (up from 87 cases on Monday).

table of updated cased in child care settings

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 Ontario wide data which show rare hospitalizations and only 1 death to date in the pandemic (click here).

Long term care facilities (LTC): 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). Deaths in nursing homes account for 66% of all deaths in Ontario, click here. There were have been 7 new deaths in our LTCs since my Monday note. The reforms required to make our LTCs safe are simple to understand but expensive to implement: 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. 

We want to protect residents of LTC facilities but we can’t do this by locking them up and denying them access to family members and loved ones. The emotional trauma, despair and grief caused to people in LTCs in wave 1 is a story that is not yet fully told. In wave 2 we need to do better. LTC residents must be allowed to have ongoing access to their families and friends, while we protect them with proper screening, PPE, better accommodations and properly trained and well paid support staff. If we fail in the mission of maintain social connections for LTC residents, the consequences will be as dire as failing to control COVID-19 infections.

chart summarizing data of COVID-19 in LTC

The rate of deaths from COVID-19 in Ontario has slowed in residents of Ontario LTCs with 7 deaths since Monday

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 195 cases of COVID-19/100,000 residents whilst Weston has 2412 cases/100,000. Even in the well-off neighbourhoods rats have doubled in the past month. 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 have over1000 cases/100,000 population). 

map of Toronto highlighting confirmed and probable cases to date

Canada’s second wave: We have had 174,998 cases of COVID-19 in Canada and 9554 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, Manitoba (see bottom left below). As a country, we are in the second wave of the pandemic (top center-upward deflection of orange curve).

graph of covid-19 data in Canada

COVID-19 in Canada as of Oct 8th 2020.

COVID-19 testing: Ontario SARS-CoV-2 testing continues at a rate that exceeds the national average of 23.2%, with 29.4 % of Ontarians tested to date ( click here). Our overall positive test rate in Ontario still remains low but has increased since Monday, from 1.33% to 1.99% (see lower middle panel on Figure above). However, there is an important caveat! In some areas, such as certain neighbourhoods in Toronto, positive test rates exceed 10%: This is a reminder that while COVID-19 is global its impact varies greatly even from one neighbourhood to the next

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 36 million cases (a jump of almost a million cases since Monday): There are now 36,281,192 cases globally and there have been 1,057,625 deaths. The number of cases has more than doubled 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. The USA with 7,564,269 cases and 212,154 deaths tops the COVID-19 list and accounts for ~20% of the global pandemic. India 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:

global map ranking the covid-19 cases, deaths and recovered in Canada

Thanksgiving wishes: To my colleagues in the DOM, colleagues and staff at Queen’s University, nurses, staff and trainees at KHSC: We are entering mile 18 of a COVID-19 marathon and some of us are tiring after months balancing school, kids, work, fear and annoyance. We have survived unkempt hair, irrational daycare policies, changes in our work load and case mix, financial insecurities and more. For the most part we have done it with professionalism. I am so impressed with the good humour, kindness, creativity and spirit of our broad and diverse team. You are an inspiring group. Don’t lose sight of the fact that what you do matters! This holiday weekend I will be giving thanks that I have such great people helping me look after my patients and working to make KHSC and Queen’s a force for good. So enjoy your turkey and pumpkin pie and while you digest it lift a glass of your favourite beverage and toast yourself for being #awesome (as we say in the DOM).

neon #Awesome

I close with a picture of Cindy Bolton and several team members at Beechgrove, who are tirelessly working to provide timely community testing for COVID-19. I salute you!

screen shot of zoom meeting


 

 

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