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Screenshot of News article - Ontario changes COVID-19 testing guidance

September 24, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

Today’s Headlines

1) A useful analysis of Public Health Agency of Canada (PHAC) data by CBC writers on how COVID-19 affects Canadians (and how this is changing over time)-click here

2) School daze 2 (the sequel)-Provinces are responding to the reality that runny noses in children rarely mean they have COVID-19 by changing stay-home policies for young students (click here).

3) Ontario is in wave 2 of the COVID-19 pandemic with over 400 new cases/day

4) The province has just announced today that we should not test asymptomatic people unless they have a confirmed COVID-19 contact.

5) On Saturday we will be moving our community COVID-19 testing facility from the Leon Center to Beechwood.

1) How is COVID-19 affecting Canadians. A caveat to start this segment-PHAC only has data on a small number (7%) of the total cases in Canada, so the following snap shot is imperfect. Nonetheless, this article presents some interesting data. 

First there has been a shift in the epidemiology of COVID-19 over the past 9 months since the pandemic began. In the beginning the disease was primarily occurring in older Canadians, now it is primarily (but not exclusively) occurring in young adults (age 20-30 years). The CBC article has a nice moving graph showing the change in age of infection since the beginning of the pandemic. It’s important to remember that older people remain much more susceptible to developing serious complications of infection (including hospitalization and death) than are young adults, even though young adults are more apt to get infection.

A second point, relates to the symptoms COVID-19 causes. While people can be infected and have no symptoms (and these people are a potential source of infection), it is equally true that the predominant disease spreaders are sick (i.e. symptomatic). This make sense because COVID-19 spreads by droplets and when a symptomatic person coughs there are many more droplets produced than when an asymptomatic person simply breathes. What symptoms does COVID-19 cause? As you can see in this “heat map” (below), where a darker shade of red indicates that more people have the symptom, the main symptoms of COVID-19 is cough, followed by other (loss of taste and smell) and fever. This is true across all age groups. SARS-CoV-2 is a virus that loves to attack lungs more than any other organ, so cough is the expected major symptom. People under age 50 years are more often presenting with runny noses and sore throats then older people. 

Graph - Symptom frequency by age

Symptoms in people with COVID-19 vary somewhat with age

A third point is that the people who are dying of COVID-19 are older (see graph below).

Graph - confirmed COVID-19 deaths by age

All age can be infected with COVID-19 but death is largely in people over the age of 50 years in Canada and is rare in children

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. For parents with young children the graph above offers reassurance that is rarely lethal in children.

Table - Status of COVID-19 Cases in long-term care homes

66% of all deaths from COVID-19 in Ontario have occurred in residents of long term care facilities (LTC)

2) School daze 2 (the sequel)-why we can and must reduce testing in this age group: British Columbia has taken a lead in bringing some sense to symptoms that require a child to stay home form schools and Day care (click here). Although I received some push back form colleagues who care for children, it remains a fact that COVID-19 remains less common in children and their outcomes are much better, especially for toddlers and those in elementary school. This does not equate to ignoring our children. However, without some balance the testing of children with runny noses will swamp our testing capacity. For example, our testing turnaround time was 12 hours and with the increased demand (1000 tests/day) has ballooned. In the community setting results may not be available 96 hours in some centers. Once COVID-19 testing times extend beyond 24 hours the value of testing begins to deteriorate, as people have to quarantine for excessive periods while awaiting results, increasing absenteeism form work, and/or we risk that infected people continue to expose themselves to society and spread infection. While we can always increase test capacity, we also need to focus testing where it is needed.

List of 7 top symptoms BC is testing

BC now only tests children with the 7 top symptoms (see above)

This is not only necessary but also is safe.

A reminder of the low levels of infection in school children in Ontario can be found here (click here). 

Photo of child with backpackTable - Status of COVID-19 Cases in Ontario Schools

The table shows only 101 Ontario school students have been infected to date.

Photo of child

Amongst younger children, toddlers in daycare for example, there is also a very low COVID-19 burden relative to young adults (see table below).

Table - Status of COVID-19 Cases in Ontario Child Care Centres

Only 52 children in Ontario’s licensed childcare facilities have been infected to date.

So what is the take home message? We need to be more realistic in our testing criteria for young children to avoid paralyzing our OCVID-19 testing system Also parents of young children should recognize that while their children are not immune, infections are relatively uncommon and outcomes are usually excellent for this who are infected.

3) Ontario is in the second wave of COVID-19 with 409 new cases yesterday. (click here). There have been a total of 48,496 cases, 5069 hospitalizations, and 28369 deaths to date. There was a marked increase in new cases of COVID-19 in Ontario yesterday, with 409 cases (up 0.89% from the day before). The rate of positive SARS-CoV-2 tests was 1. 0% yesterday (down 0.2% compared with prior day). Ontario’s COVID-19 prevalence rate is 326.3/100,000, 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 55.9 cases/100,000 population. Toronto has a rate 9 times higher than Kingston (536.1 cases/100,000 population). The region with the highest prevalence of COVID-19 remains Windsor (618.4/100,000), largely because of a poorly regulated agricultural sector and suboptimal housing of farm workers.

Map - regional variations in Covid-19 infections in Ontario

Regional variation in COVID-19 infections in Ontario Sept 24th

Hospitalization rates in Ontario have not yet begun to rise (see graph below); but once the infection begins in one demographic (young adults who readily socialize and move through the community) it will spread to older people. These older people, especially those with co-morbidities, tolerate the infection poorly and likely will soon increase the demand for hospitalization.

Graph - Comparing active and hospitalized cases

A second wave of COVID-19 has begun in Ontario (blue) but there are no increase in hospitalizations...yet! (note the black line)

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. 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.

Graph - cases by age, active, resolved, deaths

Most active COVID-19 case in Ontario are in young adults

The current reproductive rate (Ro) in Ontario is up to 1.4 (meaning the disease is once again spreading in the community). Our response must include: prioritizing who we test and ensuring rapid test result availability, limiting indoor assembly, and addressing the key demographic who are infected (young adults). Re: indoor assembly, we will need to continue respecting our bubbles and not broadening our circle of contact (see my note on Monday re new provincial policies that began this change).

4) Ontario just announced today that we should not test asymptomatic people unless they have a confirmed COVID-19 contact.

Screenshot of News article titled: Ontario changes COVID-19 testing guidance, shifts focus to symptomatic testing

In response to a testing backlog of 50,000 case, the Associate chief medical officer of health Dr. Barbara Yaffe has announced that testing needs to be reserved for people with symptoms, or those who have come into contact with someone who has COVID-19 (click here). There may be capacity at some pharmacies where people can make appointments for COVID-19 testing (not sure there are any in Kingston-stay tuned). 

Local COVID-19 Update KFL&A: 

There have been 3 new COVID-19 cases in our region since my note last Thursday, and the total number of cases since the pandemic began is now 122 cases. Currently there are 8 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 2618 COVID-19 tests in the past 3 days at KHSC. There were 11 positive tests (0.4% positive rate), 3 positive tests were from KFL&A. We did over 1000 tests yesterday! Our KHSC turnaround time for results remains under 24 hours. An amazing job by our clinical laboratory at KHSC-thank you!!!

Ambulatory COVID-19 Testing: We are seeing greatly increased community demand for testing at the Leon's Center. 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 125 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). Two advances: We are starting to do multiplex testing for influenza and RSV on selected children. On Saturday we will be moving our testing facility from the Leon's Center to Beechgrove Complex. 

Kudos to the amazing KHSC team, led by Cindy Bolton, that runs our community testing centre-they work hard. I would encourage any of you to send them a note of thanks! 

Challenges to KHSC capacity Our bed capacity has again been reduced as the hospital gets busier with more admissions (see today’s data below). We have 78 available beds (versus 77 last Thursday). We continue to have good ventilator capacity. There 55 ALC people currently in KHSC.

Graph - KHSC Hospital Capacity

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 continue to encourage 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.

17 or more neighbourhoods in Toronto have a COVID-19 prevalence of over 1000 cases/100,000 population (click here). Here is the state of the second wave of COVID-19 in Toronto (click here

Graph - Toronto Covid Data

The second wave in Toronto

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 111 cases of COVID-19/100,000 residents whilst Weston has 2045 cases/100,000. 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! 

Canada’s epidemic at the beginning of the second wave: We have had 148,162 cases of COVID-19 in Canada and 9244 deaths (see below) since the pandemic began. Most cases (87%) are resolved. 

Graph - Canada COVID 19 Data

COVID-19 in Canada as of Sept 24th.

COVID-19 testing: Ontario SARS-CoV-2 testing continues at a rate that exceeds the national average of 19.9%, with 25.4% of Ontarians tested to date ( click here). Our overall positive test rate in Ontario still remains low (1.32%).

Graph - SARS-CoV2 Testing in Canada as of Sept 24th 2020

SARS-CoV2 Testing in Canada as of Sept 24th 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 4.9% (up slightly again) (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 31,969,940 cases globally and there have been 978,059 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). There are approximately 37 countries that have had a total of more than 100,000 cases and I can no longer capture the screen on one page! The USA with 6,945.987 cases and over 200,000 deaths sadly tops the COVID-19 list and accounts for 22% of the global pandemic. India now has the second largest number of cases (see list of countries with the most cases below left). I am now showing countries with more than 200,000 cumulative cases.

Table - Cases by Country/region (Deaths)

Countries with over 200,000 cumulative cases

A note to the nurses and health care team at KGH and Hotel Dieu: Many of you are stressed and many are struggling, some are frustrated, some are angry, all are concerned. There are huge logistical challenges that each of you face (beyond the normal challenges of a life in nursing or medicine). The current daycare and school stay home policies make it hard to work and look after children. Many are experiencing increased patient care responsibilities. Short staffing on busy wards is a problem as we attempt to hire more nurses (from a very limited pool). 

I have no magic answers. I would just highlight that you are engaged in a truly noble struggle to provide care for our community in a pandemic. This is the stuff that is worthy of Florence Nightingale and William Osler. You can be proud of yourselves!

We are in this together and your medical colleagues appreciate you whether you are in environmental services, switchboard, occ health, nursing, pharmacy, the lab …. the list goes on.

A heartfelt thank you, from me to you!!!

Cartoon heart with message: A heartfelt thank you

Stay well!

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