September 21, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
1) A surge in COVID-19 in young people in Ontario: a second wave of COVID-19 as Ontario experiences >400 new cases per day
2) School daze-lots of anxiety and confusion in provincial policy around testing in daycare and elementary schools (despite little COVID-19 infection in these sites). A new threat to operation of our testing and health care facilities
3) New rules on maximum group size for unsupervised social activities
1) Ontario continues to experience increased numbers of new COVID-19 infections, ~ 415 per day. This rise in case numbers appears to represent a second wave of disease in Ontario (click here). In the top left graph you can see the recent rise in cases, coincident with return to schools and universities and seasonal changes in the weather. Thus far there is no increase in rates of death (bottom left). However, COVID-19 deaths largely occur in elderly and frail people, such as residents of nursing homes, whereas the current spike in infections is very much affecting young adults.
Beginning of a second wave of COVID-19 appears to have begun
Hospitalization rates have also not yet begun to rise (see graph below); but what tends to happen with COVID-19 is that infection begins in one demographic (usually young people who can readily socialize and move through the community) and only later spreads to older groups. These older groups, especially those with many comorbidities, tolerate the infection poorly and will require hospitalization.
No increase in hospitalizations...yet! (note the black line which is hospitalizations)
As shown below, most of the active cases in Ontario, per Ministry of Health data, are in young people (< age 30 years-blue part of bar, left below) and most cases are in Toronto, Peel and Ottawa (see active blue cases on the bar graph, right below).
Most active case are in young people in Toronto, Peel and Ottawa
Throughout the pandemic young people have tended to be commonly infected; but suffered much less morbidity and only 12 fatalities have occurred in people under the age of 40 years in Ontario. If you want to see how a few young people can cause a significant outbreak of COVID-19, click here and look at this interesting contact tracking map from the recent outbreak at Western University (another reason not to smoke or go to large group gatherings!).
As you read the headline below think about where Ontario needs to focus its efforts-it’s on young adults, not on toddlers!
2) School daze: Parents are being inundated with conflicting rules about what to do when their young child is sick. In general they are being told that prior to a child with cough, runny nose or fever returning to daycare or elementary school their child must have a negative COVID-19 test and improvement/resolution of their symptoms. In my opinion, the current policies re testing and attendance for children are not rationale. I base this opinion on the low infection rates and low individual risk of COVID-19 in children of day care and elementary school age. Current policies are not feasible and cause substantial absenteeism from work while swamping our testing capacity with unnecessary (and almost always negative) tests of children. Moreover, because each episode of infection is a separate instance, last week’s negative test does not count if a returned student develops new or persistent symptoms. So the need to leave school and be tested would affect each child each time an infectious symptoms occur. Consider this sobering fact: children develop on average six viral respiratory tract infections each year (click here).
Jason Leitch, Scotland’s national clinical director, yesterday responded by sending a message directly to parents and guardians. In the email, he said that children with mild cold-like symptoms did not need to be tested or to isolate and could safely continue their education in most cases (click here).
The absence of parents from the workplace that results from over-testing and very stringent stay home policies is causing havoc. In the healthcare field is a major threat to us continuing to operate hospitals and clinics. Parents are being pulled out of the workforce as they must now wait in long lines for testing, which almost always yields negative results. This is also slowing testing for the people who actually are at risk of COVID-19, namely young adults.
So what are the facts about COVID-19 and young children (elementary school age and younger). COVID-19 infections are much less common in young children and when they occur cause less serious consequences in the vast majority of children.
What is actually happening in Ontario in terms of COVID-19 infections in children in licensed child care facilities? Ontario has 5,500 licensed child care centres and over 120 licensed home child care agencies. As you can see in the table below, only 0.32 centers have reported a case of COVID-19 and there have been only 76 cases in children in these centers across the province since the pandemic began. So children in child care centres account for 76/46,849 or only a miniscule 0.16% of all COVID-19 cases (click here):
COVID-19 is rare in young children in Ontario
These data justify the province reconsidering its policies on school management in the COVID-19 pandemic. We need a more balanced and uniformly administered approach to COVID-19 testing and stay home policies for daycares and elementary schools. These are not just my views but actually reflect policy in many countries. In Scotland, parents are being reminded that a runny nose is not a reason to have their child tested. Clear guidance to this effect would be welcome in Ontario. Children get many infections (rhinovirus, respiratory syncytial virus etc.) and SARS-COV2 is nowhere near the top of that list!
Are their data to support Ontario’s current policy? The short answer is no. A change in policy is not a “nice to have” it’s a must have! In the short term we need to expedite testing for families of essential workers in healthcare if we want to keep the enterprises we rely on working! We are already experiencing trouble covering essential health care workers who are suddenly forced to stay home awaiting COVID-19 test results in our children. I encourage the Ministry of Health to consider the epidemiology and logistical realities and rapidly change their policies to avoid causing unintended adverse consequences for society,
3) Counting to 10: new rules on maximum group sizes in Ontario: The coronavirus is highly contagious and is spread by droplets from the nose and throat. Thus the usual means of infection is to be within 6 feet of an infected person for some period of time (usually more than 5 minutes). An important means to slow community spread is to avoid assembling in large groups, particularly with unmasked people (see note above on Western University outbreak). Other key infection prevention measures are maintaining physical distancing, frequent hand washing and wearing a mask indoors.
In this spirit, Mr. Ford issued a new Ontario policy that prohibits unmonitored gatherings of more than 10 people (indoors) and 25 people (outdoors), for the next 28 days (click here). Those who break these rules face a minimum fine of $10,000 for the organizers and a $750 fine for guests. Events held in staffed facilities are excluded, such as movie theatres, places of worship, gyms and convention centres. Likewise this does not supersede our already rigorous policies for our blended Zoom and in person Medical Grand Rounds, which limits numbers of people in the auditorium, spaces people per protocol, and requires masking.
Local COVID-19 Update KFL&A:
There has been 1 new COVID-19 case in our region since my note last Thursday, and the total number of cases since the pandemic began is now 119 cases. Currently there are 6 active cases locally and they are recovering in the community (see update from KFL&A Public Health). There are no cases in KHSC. We have performed 2222 COVID-19 tests in the past 3 days at KHSC. There were 2 positive tests, 1 was a Queen’s student and 1 from the Kawartha area.
Ambulatory COVID-19 Testing: We are seeing greatly increased community demand for testing at the Leon Center because of a Provincially-mandated testing of children with upper respiratory symptoms (as discussed above). Demand is also being driven by people coming from out of region (because testing centres in Ottawa are swamped too). Most regional testing centers are being overwhelmed and some are closing prematurely (before advertised operating hours end) because of lack of capacity. Locally, we are testing 400 people per day at the Leon Centre, with a wait time of 2 hours and 30 minutes. We also do another 100 tests/day at the Queen’s satellite site. A reminder re hours of operation: People start lining up at the Leon Center 0630 but the doors do not open for testing until 1000 (and posted wait times are based on the time of scheduled opening).
COVID-19 app: The parameters for a positive ping on this app (indicating potential exposure) is that the blue-tooth tracking mechanism identified you as being within 10m of a person with a positive test for 15 minutes. If you are pinged and at work at KHSC, please continue your shift and contact occupational health, who will arrange expedited testing. While I understand the rationale for the app, it is unclear to me that it is helpful and would rely instead on attention to nonpharmacologic interventions and self-monitoring for COVID-19, contact tracing etc.
Challenges to KHSC capacity Our bed capacity is improved a bit compared with last week. We have 105 available beds (versus 77 on Thursday last week). We continue to have good ventilator capacity.
Bed capacity at KHSC Sept 21st 2020
Care of the 99.9%: Our outpatient clinic volume remains at only ~50% of what it was pre-COVID-19. The leading causes of death in Canada remain cardiovascular disease and cancer, not COVID-19 (click here). Thus, out faculty and staff need to provide care for the 99.9% of patient who do not have COVID-19. Consequently, I have encouraged 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 47,274 cases, 5022 hospitalizations, and 2829 deaths to date. There was a marked increase in new cases of COVID-19 in Ontario yesterday, with 425 cases (up 0.9% from the day before). The 1.50% rate of positive SARS-CoV-2 tests yesterday (up 0.1% compared with prior day) has been gradually increasing over the past week.
Ontario’s COVID-19 prevalence rate is 318/100,000, 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 55.5 cases/100,000 population. Toronto has a rate 9 times higher than Kingston (523.1 cases/100,000 population). The region with the highest prevalence of COVID-19 remains Windsor (616.5/100,000), 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 Beaches has only 102 cases of COVID-19/100,000 residents whilst Weston has 1979 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!
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.
Canada’s epidemic: We have had 143,649 cases of COVID-19 in Canada and 9217 deaths (see below) since the pandemic began. Most cases (89%) are resolved. While the situation for Canada remains good (i.e. there is not yet a national second wave). However, there are several focal outbreaks in BC, Ontario and Quebec. We need to control these through good public health measures, while continuing to keep society open. In many cases these outbreaks relate to simple but refractory social justice issues, like poor and crowded housing and low income, as well as some educational challenges (getting young people to respect public health guidance). The solutions to COVID-19 outbreaks will likely be better achieved by addressing these social determinants of health.
COVID-19 in Canada as of Sept 21st.
COVID-19 testing: Ontario SARS-CoV-2 testing continues at a rate that exceeds the national average of 19.1%, with 24.5% of Ontarians tested to date ( click here). Our overall positive test rate in Ontario remains low (1.32%).
SARS-CoV2 Testing in Canada as of Sept 21st 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 4.6% (falling each week). Despite an encouraging decrease in the rate of positive tests in the US, down >3% over the past month (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 31 million cases: There are now 31,110,407 cases globally and there have been 961,544 deaths. The number of cases has almost 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). 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).