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September 17, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

Today’s Headlines

  1. A surge in COVID-19 in young people in Ontario-possible beginning of second wave of COVID-19 as Ontario continues to have ~ 300 new cases per day
  2. KFL&A Public Health has asked Queen’s to enforce rules and discipline offenders
  3. Parents we are with you in spirit!
  4. Some clarifications re the COVID alert app

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  1. Ontario continues to experience increased numbers of new COVID-19 infections, ~ 300 per day. There is a rise in case numbers in Ontario which if it continues would represent a second wave of disease (click here).
graph with blue lines showing start of 2nd wave

Beginning of a second wave of COVID-19 appears to have begun

As shown below, most of these cases, per Ministry of Health data, are in Toronto, Peel and Ottawa (see active blue cases on the right of the bar graphs).

graph listing Ontario health units with most cases

Most active case are in 3 locations

Throughout the pandemic young people have tended to be commonly infected; but in general have suffered much less morbidity (not as sick) and only 1 fatality (in Ontario). This graph shows the overall age distribution amongst all infected people to date. Note the highest rates of infection are in 20-29 year old people.

graph showing COVID-19 cases by age

Most new active infections (in blue) are in University age people (age 20-29). (click here).

Mike Crawley has written a nice summary of the surge in COVID-19 cases seen in the past week (click here). There are no surprises but the messages bear repeating and basically relate to community spread of the virus in some Ontario cities (Toronto, Ottawa and the Peel region). The new cases are primarily in young adults (university age). 

When the virus spreads in the community, contact tracing is tough because the contact event may not be impactful and thus may be unknown to the individual (i.e. our infections now are not the result of a group of people that all went to a nail salon). Instead we are seeing the consequences of allowing groups of 50 people to assemble (permitted per Ontario’s Phase 3 opening policies). In these scenarios it is challenging to maintain physical distancing and even masks are not 100% effective. Infection may result from proximity to a person who is minimally symptomatic or asymptomatic people and the contact may not be memorable. The graph below is a reminder that increasingly we lack the ability to identify where the infection originated (i.e. contact tracing is more often, than in the past, failing to identify a source-the dark blue part of the pie). This reflects increased community spread.

Pie graph showing source of transmission of COVID-19

A recent rise in the number of cases where contact tracing is not possible or not revealing the source of infection (dark blue part of pie)

Local COVID-19 Update KFL&A: 

There have been 2 more cases of COVID-19 in our region since my note on Monday, bringing the total since the pandemic began to 117 cases. Currently there are 5 active cases locally and they are recovering in the community (see update from KFL&A Public Health) (see graph).

graph showing new cases by date in KFL&A

COVID-19 in KFLA; 5 active cases recovering in community

We have performed 1757 COVID-19 tests in the past 3 days at KHSC. There were 4 positive tests, 3 from Perth Smith Falls and 1 from the Kawartha area. There are no inpatients with COVID-19 in KHSC. We are seeing greatly increased community demand for testing at our assessment centers. Provincially testing is on a marked rise as children return to school (see graph below). Locally we are testing 400 people per day at the Leon's Centre, with a wait time of 2 hours and 45 minutes. We also do another 100/day at the Queen’s satellite site. We have done over 1000 test batch runs of COVID-19 tests since the pandemic began (KUDOS Lab team!!!).

graph showing number of COVID-19 tests performed in Ontario by month

 

2.  Queen’s University to discipline students that don’t comply with public health directives (click here):This is worth a read. Kingston’s two post-secondary institutions say they are ready to use their codes of conduct to sanction students who do not follow coronavirus legislation — if necessary, to the point of expulsion — even when off campus…..”

screenshot of Queen's university welcome sign and building

3. ​​Parents we are with you in spirit! We recognize that parents are receiving mixed messages from the schools regarding the policies for COVID-19 testing in children with symptoms of an upper respiratory tract infection and on policies relating to their return to school. This is challenging, especially as common viral infections, like rhinovirus, are MUCH more common in daycare and elementary school kids than is COVID-19, which remains relatively rare. The local school policies are not (in many cases) aligned with provincial policies. That said, The Dept. of Medicine will be flexible with its staff and physicians as they deal with their family situations. I am confident clarity will emerge over the coming weeks. 

stop sign with proceed with caution on it

4.  Some clarifications re the COVID alert app: The COVID app, which works on iPhone and Android OS is recommended by the government and public health.

screen shot of covid-19 alert app

There are virtues in the alerts which tell you that you have been within close proximity of a person that tested positive (i.e. 15 minutes of proximity within the past 2 weeks). If you are alerted you are advised by the app to self-isolate and to get tested. One of my colleagues, Karley Salsbury agreed to share her experience. She received notification that she had been exposed (had no idea to whom, or when or where, because the system is entirely confidential). She went and got tested as instructed. She self-isolated and received a negative test result within 24 hours. She then continued to self-monitor for 5 days at which time the app said that there was “no exposure detected” (which is confusing)!

How does this system work? If you test positive you receive a 1 time key number that allows you to voluntarily upload your positive status to the app. The concern that Karley and others have is the notification causes you to become your own public health detective and the instructions around isolation and self-monitoring are vague. Whether, how and for how long you isolate are largely left to your own discretion. Karley wonders if an exposure as defined by this app as exposure to a known contact, as occurs with contact tracing (my answer is no!). So, the app is good idea but further clarifications and evolution are needed to avoid engendering unnecessary concerns and to clarify the appropriate response to a positive notification.

iPhone screenshot of covid alertiPhone screenshot of covid alert you've been exposed

Karley’s notification screens -shown with her permission

Challenges to KHSC capacity Our bed capacity has contracted as we have more ALC patients and more elective procedural cases in hospital. This is particularly problematic in the Medicine program (see graphic below), which is almost half the hospital’s bed capacity. Bed capacity is monitored actively to ensure we can clear capacity should there indeed be a second wave of COVID-19. We do have good ventilator capacity. There are now 60 ALC patients. These people should not be in hospital (by definition -because they have no acute medical problems). These people should be in nursing homes and retirement homes or in their own homes. They are occupying precious inpatient beds and KHSC is the only tertiary care hospital for all of southeastern Ontario. At KHSC we have no willingness to have patients in hallways, because it increases the risk of infection spread and so we are working hard to accelerate transfer of patients who are admitted from the Emergency Department to an inpatient bed. This is why we need to resolve the ALC bed occupancy issue!

KHSC bed management at KGH

Limited bed capacity at KHSC Sept 17th 2020

Meanwhile, despite concerns about inpatient volumes, our outpatient clinic volume remains at only ~50% of what it was pre-COVID-19. I am encouraging all physicians in the Department of Medicine to ramp up their in person patient clinic visits to deal with a backlog of disease while our local epidemiology permits us to safely do so. This request is fully aligned with KHSC policy.

Ontario’s COVID-19 epidemic-a continued rise in new cases: (click here). There have been a total of 45,676 total cases, 4987 hospitalizations, and 2825 deaths to date (a downward revision of the number of deaths based on updated source documents). There were 293 new cases of COVID-19 in Ontario yesterday (up 0.6% from the day before). The 1.30% rate of positive SARS-CoV-2 tests yesterday (up 0.1% compared with prior day) remains stable though slightly increased. The fact that it hasn’t risen more likely reflects more testing of concerned but asymptomatic people (who have low likelihood of testing positive). Ontario’s COVID-19 prevalence rate is 307.3/100,000, up significantly from a month ago, when it was 263.8/100,000. This provincial rate is much higher than in KFL&A, which has a prevalence of 54.5 cases/100,000 population. Toronto has a rate 9 times higher than Kingston (505.6 cases/100,000 population). Toronto has just passed the 500 cases/100,000 threshold for the first time. The region with the highest prevalence of COVID-19 remains Windsor (612.5/100,000), largely because of a poorly regulated agricultural sector and suboptimal housing of farm workers.

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 Beacheshas only 102 cases of COVID-19/100,000 residents whilst Weston has 1962 cases/100,000 (see map below)! Thus, there is no single “Toronto”, as seen through a COVID-19 lens; it’s a diverse patchwork with a 19-fold variation in disease prevalence. Half of Toronto’s neighbourhoods have very high disease prevalence!

Map of GTA showing areas of prevalence by neighbourhood

Each dot is a neighbourhood. All dots from the highlighted one at the bottom of this map to the right end of the graph are neighbourhoods that have more than 1000 cases of COVID-19 per 100,000 residents.

COVID-19 is affecting certain racial and economic groups disproportionally. As I mentioned on Monday, there is a much lower prevalence of COVID-19 in white people than in other races. Today see the data showing that low income people are also disproportionately impacted. People with incomes <$30,000 account for only 14% of Torontonians but constitute 27% of COVID-19 cases (see graph below) (click here). The best way to stop the epidemic in Toronto is to address housing conditions in its poorest neighbourhoods and focus on broader equity and inclusivity initiatives.

graph of covid 19 cases by household income in Toronto

Disproportionate impact of COVID-19 in Toronto on low income people

Canada’s epidemic: We have had 140,539 cases of COVID-19 in Canada and 9199 deaths (see below). Most cases (89%) are resolved. While the situation in Canada remains good, with low levels of hospitalization, case activity is increasing as discussed previously in this note. We are either seeing the effects of several focal outbreaks or the beginning of a second wave. Thus, ongoing attention to nonpharmacologic measures is essential (hand washing, 6 feet of physical distancing, masks in indoor spaces, stay home if you’re ill).

Map of Canada highlighting COVID-19 cases by province

COVID-19 testing: Ontario SARS-CoV-2 testing continues at a rate that exceeds the national average (which is 18.5%), with 23.7% of Ontarians having been tested to date ( click here). Our positive test rate in Ontario remains low (1.34%).

graph showing covid-19 testing in Canada

SARS-CoV2 Testing in Canada as of Sept 17th 2020

In contrast with Canada’s 2.0% rate of positive tests, the USA has an average rate of positive COVID-19 tests of 5.4%. Despite an encouraging decrease in the rate of positive tests in the US, down ~ 2-3% over the past month (click here), the US-Canadian border will remain closed for routine travel at least until the end of October (at least).

The COVID-19 global pandemic : There are now 29,960,718 cases globally and there have been 942,631 deaths. The pandemic hot spots are in the Americas (Brazil, Mexico, Peru, Chile and USA), India and Russia (click here). The USA accounts for 23% of the global pandemic. India now has the second largest number of cases (see list of countries with the most cases below left). Globally the case load has not flattened, although the rate of increase is slower than in March.

Stay well!

 

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