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

headlines

1) American COVID-19 testing results and the ongoing differences re when the US border will reopen (click here)

2) What are the effects of public health measures on all cause morality? (Bilinski and Emanuel JAMA Oct 112 2020, click here)

3) COVID volumes stabilize in KFL&A community (see update from KFL& A Public Health). 

4) Compassionate exemptions for persons returning to Canada that require a quarantine exemption to see a loved one in hospital: new Public Health Agency of Canada (PHAC) policy

5) The second wave of COVID-19 in Ontario now matches the 1st wave, (click here

1) American COVID-19 testing results and ongoing differences regarding when the border will reopen: In contrast with Canada’s 2.0% rate of positive tests, the USA has an average rate of positive COVID-19 tests of 5.3% (and it’s slightly up over the past 2 weeks-see below) (click here). 

graph showing US testing vs positive

Rates of positive COVID-19 tests slowly increasing in the US again

It has been 7 months since the Canadian US border closed to routine travel. On Monday, the Canadian government announced that the Canada-U.S. border closure will be extended until at least Nov. 21, 2020. Mr. Trudeau and Mr. Trump are at odds as to when the border will reopen (“until the US rates decline” vs “Any day now”) (click here). In an interview Wednesday on Winnipeg podcast, The Start, Trudeau said Canada plans to keep the border closed as long as COVID-19 case counts in the U.S. remain high. In contrast, Mr. Trump said on Sept. 18,"We're looking at the border with Canada — Canada would like it open." I am pretty sure we won’t see border opening for routine travel until rates of positive COVID-19 tests are similar between the USA and Canada.

photo of president trump and prime minister Trudeau

2) What are the effects of public health measures on all cause morality and COVID-19 mortality? (Bilinski and Emanuel JAMA Oct 112 2020, click here)

There is a lot of bluster form Donald Trump about how great the US is doing with COVID-19. Here is yet more evidence that says this is not the case. In a new paper in the journal JAMA, Bilinski et al compared US COVID-19 deaths and excess all-cause mortality in 2020 (vs 2015-2019) to that of 18 countries with diverse COVID-19 responses and varying mortality rates. They did two interesting analyses, one looking at what would have happened in the US had had the same mortality rate as other countries, either at the beginning of the pandemic (~Feb 2020) or by May or June, 2020 ,when public health measures had time to kick in. The other thing they did was very pragmatic, simply estimating excess all-cause mortality by counting the difference between mean 2020 deaths (which include a COVID-19 pandemic) and deaths in corresponding weeks during the years 2015-2019 (when there was no pandemic). All cause mortality is exactly what you would guess-the sum of all people who die from ANY cause, not just COVID-19. They divided countries into low, medium and high COVID-19 mortality rates (Canada was medium)-see Table 1 below

president trump at rally

Trump holding rallies without masking (click here for CNN story).

Compared with the start of the pandemic all countries are improving in terms of COVID-19 mortality rates (deaths/100,000 population); however, the US has improved the least and as of the summer of 2020 was experiencing excess mortality from COVID-19 that are several fold higher than those we are seeing in Canada (and we are in the moderate mortality rate group ourselves) (Table 1 below).

table of covid-19 mortality in the US vs other countries

In terms of COVID related-19 mortality the USA as judged since the beginning of the pandemic the US is #3 (#1 being the worst), just below Belgium and Spain. However, as judged by rates from May onward, US mortality rates remained high (36.9 deaths/100,000 population) whilst mortality rates from COVID-19 fell in all 6 of the comparator “high morality” countries (bottom third of table above). As judged since June 7th, this disparity only worsens with the US at 27.2 deaths form COVID-19/100,000 whilst the next closest countries are Israel and Sweden, with 10.6 and 10.0 deaths/100,000 population. In all other countries the excess COVID-19 mortality fell. For example, since June in Italy the death rate was 3.1 deaths/100,000 population whilst the US death rate remains 9 times higher, 27.2 deaths/100,000 population (Table above). It is estimated that if the US COVID-19 death rates had occurred at levels seen in Australia, the USA would have had 187, 661 fewer COVID-19 deaths (94% of reported deaths), and if comparable to Canada, 117 622 fewer deaths (59%).

table of excess all cause mortality

Table 2 above shows some good news. In countries with moderate COVID-19 mortality, there was minimal excess in all-cause mortality despite the pandemic (first column in table above). In countries with high COVID-19 mortality however, excess all-cause mortality reached as high as 102.1/100000 in Spain, even higher than in the USA (71.6/100000). However, since May 10 and June 7, the excess all-cause mortality has disappeared in all comparator countries, except the USA, which remains high at 19.4 excess deaths/100,000 population (Table 2). 

These are not randomized trial data and the US population has more comorbidities than many countries (which predisposes to higher mortality) ; but on the other hand is relatively younger than most European countries (which is normally reduces mortality). One can speculate, as the authors do, that America’s “weak public health infrastructure and a decentralized, inconsistent US response to the pandemic” squandered an early advantage and resulted in a world leading, excess mortality rate. While not definitive these data suggest that the public health approaches countries take have consequences and a laissez faire approach, as seen in the USA with disagreement about issues as basic as masking and physical distancing, has dire consequences for public safety 

3) COVID volumes stabilize in KFL&A: There have been 3 new COVID-19 cases in our region since my note last Thursday. The total number of cases since the pandemic began is now 170 (up 3 cases since Thursday). Currently there are 9 active cases locally (down from 12 cases on 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 but we do have 1 person who is quarantined because of potential COVID-19 exposure. The KHSC lab did 1057 tests over the weekend. Thus latest lab rate of positive tests is only 0.2 were positive.

graph showing covid-19 new cases by date positive received

This local stability in COVID-19 allows us to continue to provide patients with much needed health care for the many diseases other than COVID-19.

4) Compassionate exemptions for persons returning to Canada that require a quarantine exemption to see a loved one in hospital: new Public Health Agency of Canada (PHAC) policy: The pandemic has seen some heart wrenching separations of family members due to closed borders, travel restrictions, and the need to quarantine for 14 days upon entry to Canada. It is not rare that people from outside Canada wish to return to Kingston to see a loved one who is dying or having a life-changing circumstance. PHAC, Canada’s public health agency, requires people returning to Canada to self-quarantine for 14 days. However, for families of hospitalized patients who are near death this quarantine may be “too long”. PHACs position until recently was that no exemptions were given for compassionate reasons (see Tweet below). Last week PHAC changed their position and established a process to allow compassionate exemptions. A PHAC exemption (which must be applied for) does not supersede our hospitals right/responsibilities to keep KHSC safe. At KHSC we are developing a policy to deal with requests for expedited compassionate visitation. First we will confirm that PHAC has granted an exemption and second the hospital will review the request and determine whether such a request for expedited visitation can safely occur. Exemptions will not be given to people with symptoms or known COVID-19 exposure. This is breaking news and IPAC and incident command are working on make a clear policy statement by weeks end.

picture of lady with a mask sitting in chair on cell phone

5) The second wave of COVID-19 in Ontario now matches the 1st wave There have been a total of 62,908 cases with 5542 hospitalizations, and 3031 deaths in Ontario, since the pandemic began. Hospitalizations are up 8.8% (35 cases since yesterday). The rate of positive SARS-CoV-2 tests is down to 2.0% vs a peak of 3.0% last week. Ontario’s COVID-19 prevalence rate is 423.2/100,000 (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 remains at 78 cases/100,000 population. Toronto is Ontario’s hotspot for COVID-19 (711.9 cases/100,000 population), a rate 9 times higher than Kingston. Windsor no longer has the highest prevalence of COVID-19 (645.9/100,000), having been surpassed by Toronto. Ottawa is also a hot spot at 558.5 cases/100,000.

The graph below shows that the majority of infections in Ontario are in young adults age 20-29 (blue and green below, on left). While most cases are in people under 60 year of age, almost all deaths are in people over the age of 60 years (gray on graph below) (click here). 

graph of infected people by age

Age of people infected with COVID-19 Oct 19th 2020

Note the sustained rise in hospitalizations in Ontario in the past 2-3 weeks (shown by the black line in the graph below). To put this in perspective at the peak in May we have just over 1000 hospitalizations in Ontario vs currently we have 278 people in hospital, including ICU (See below).

graph showing hospitalized active cases

What we should do in wave 2 of the COVID-19 pandemic. With careful attention to public health measures we can flatten the second wave without shutting down schools, businesses and society. To address wave 2 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.

Use the Mobile Screening Tool: Complete the COVID-19 pre-screening tool here and you will be able to “skip the line”: We are working hard to get as many patients as possible into our outpatient clinics to ensure care for the 99.9% of patients (i.e. those who do not have COVID-19 but who have a multitude of other pressing health needs). One way we physicians can help safely expedite entry of patients into our facilities is to ask them to complete the pre-screening questionnaire. This will screen out people who are sick and expedite entry to the facility for everyone else.

To all patients: Please complete your COVID-19 screening for your upcoming outpatient appointment online with the mobile screening tool. The mobile screening tool, available in English and French, 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.

screen shot off mobile screening tool

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. 

photo showing swabbing test of patient for covid-19

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: 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.

Requirements if you need to be tested

1) A valid Ontario health card or a piece of photo identification.

2) Wear a mask and maintain physical distancing at all times while in the walk-in line.

KHSC capacity-preparing for an anticipated need for hospital admission: KGH has adequate bed capacity for a COVID-19 surge (with 101 available beds-up from 62 last week) and we have good ventilator capacity (54 ventilators). 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. Our PPE supply is good, despite a global shortage of some supplies like medical gloves. In fact, the problem for KHSC is the availability of some forms of PPE for purchase.

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. The graph below shows the low incidence of cases in kids under age 10 years in Ontario (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. 

graph showing cases by age group and sex in Ontario

COVID-19 infections Counts and rates by sex and age in Ontario: Oct 19th 2020

photo of two school aged boys in a classroom

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. That said the number of cases in school age children which includes teenagers) has more than doubled over the past 2 weeks (increasing from 236 to 736 cases). 

photo of a female toddler

Amongst younger children and toddlers COVID-19 is relatively rare. 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). The rise in cases has been modest in these young children. 177 children in Ontario’s licensed childcare facilities have been infected to date (up from 65 cases 2 weeks ago).

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 1906 deaths in nursing homes account for 63% of all deaths in Ontario, click here. In the last 2 weeks the rate of death amongst LTC residents has once again begun to increase. There was an outbreak at Fairmont nursing home last week with 1 infected staff member (click here). The definition of an “outbreak” in a nursing home is quite strict and only requires 1 case to qualify as an outbreak.

graph of covid-19 data in LTC

There have been 9 additional deaths in Ontario LTCs since last Thursday

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 in friends, with proper screening, PPE and in reasonable numbers. If we fail in this the consequences are as bad as failing to control COVID-19 infections in these facilities.

COVID-19 Hotspots in Toronto

picture of a forest fire

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 218 cases of COVID-19/100,000 residents whilst Weston has 2612 cases/100,000 (see map below). Rates in both in low and high prevalence neighbourhoods, have increased each day for the past month. 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). 

map of Toronto highlighting COVID-19 cases by neighbourhood

COVID-19 in Toronto by neighbourhood Oct 19th 2020

Canada’s second wave of COVID-19: We have had 198,852 cases of COVID-19 in Canada and 9764 deaths (see below) since the pandemic began. Most cases (86%) are resolved. However it is clear the country is well into a second wave, which exceeds the first in case number but not in hospitalizations (top graph below). Also note the concerning numbers of new (active) cases in Manitoba and other provinces (orange bar in graph below left).

graph of covid-19 data in Canada by province

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

The graph below shows a very concerning trend line in Manitoba where new cases of COVID-19 are occurring and where positive test rates are more than double the national average, at 4.7%.

graph of timelines and trends in Manitoba

COVID-19 2nd wave in Manitoba: a reminder a small first wave is no prediction of the size of future waves

COVID-19 testing: Ontario SARS-CoV-2 testing continues at a rate that exceeds the national average of 25.65%, with 32.4 % of Ontarians tested to date ( click here). Our overall positive test rate in Ontario still remains low (1.38%) vs 2.07% nationally ( although the national rate had spiked to 3% last week). 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 a reminder COVID-19 is global but its impact varies greatly even from one neighbourhood to the next.

The COVID-19 global pandemic exceeds 1 million deaths and over 40 million cases (up 2 million form last week): There are now 40,186,016 cases globally and there have been 1,115,521 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 8,165,613 cases and 219,811 deaths tops the COVID-19 list and accounts for ~20% of the global pandemic. India has the second largest number of cases (see today’s COVID-19 global map below).

global map and ranking of covid-19 data by country

Stay well!

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