December 23, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

Dr. Archer's Updates on COVID-19

General DOM News & Events

| 23 December 2020

Change in policy re: COVID-19 testing:

Effective immediately all patients admitted to KHSC will undergo Covid-19 testing

1) Ontario to enter provincial lockdown Dec 26^th (click here): lockdown duration in KFL&A remains to be decided

2) Update on major outbreak of COVID-19 at Joyceville Institution (good news-no new cases) (click here):

3) KFL&A goes orange (but there is some good news) (see update from KFL& A Public Health):

4) Moderna vaccine approved today!!! (click here)

5) Current vaccines work against the new strain of SARS-CoV-2 emerges in England (click here)

6) Ontario has had 162,663 COVID-19 cases with 2408 new cases since yesterday, a 4.8% positivity test rate, and 1002 people in hospital today (click here):

7) Canada’s second wave of COVID-19: We have crossed the half million case mark with 526,371 total cases to date, with 75,117 active cases (click here)

8) The COVID-19 global pandemic has seen 1,725,057 million deaths and 78.4 million cases (click here)

9) Holiday fun: Cross Words for COVID-19 and a Thank you for staff, trainees and faculty

Regular reminders and updates:

KHSC bed capacity (not updated at time of note)
Use the Mobile Screening Tool to expedite clinic visits
KHSC visitor policy
COVID-19 testing at Beechgrove Community Assessment Center: (click here):
Increased outbreaks and deaths in Long Term Care facilities (LTC)
COVID-19 in toddlers and young children: (click here).
KHSC’s new screening questions effect visitors and health care workers differently: an introduction to “workplace isolation” for health care workers

1) Ontario to enter provincial lockdown Dec 26^th (click here); lockdown duration in KFL&A remains to be decided

Premiere Ford held a news conference at 1 pm Monday to announce a 28-day lockdown for the portions of the province south of Sudbury, ON, beginning at 12:01 a.m. on Dec 26th. He flagged an ongoing large amount of travel from high to low prevalence areas and the associated rising numbers of hospitalizations which threaten to swamp our ICU capacity (which is needed to support the care of people with many other diseases and surgical and interventional procedures, beyond COVID-19). Based on this he announced a province wide shut-down. Essential business will remain open at limited capacity and other businesses will function with curb side service. School breaks will be extended so that elementary schools resume Jan 11^th (vs Jan 25^th for high-school students).

A major gap in the lockdown is large factories and manufacturing facilities. Many of these businesses have high COVID-19 caseloads, struggle to provide proper physical distancing and PPE and most importantly many do not offer their workers paid sick time. If there is one change to Ontario labour laws that is required to stem the rise in COVID-19 in Peel and similar areas where on site work in close quarters in required it would be paid sick time. People need to come to work even when sick to be paid-a recipe for COVID-19 to spread!

Why are we doing this now with vaccines already available? Essentially Ontario’s second wave is still rising with over 15,000 new cases/week and increasing numbers of hospitalizations and ICU admissions. It will be several months, likely into early summer, before enough people are vaccinated to flatten the curve. Until then the only way to avoid hospital collapse is to reduce viral transmission through adherence to stricter public health measures. No one doubts that a lock down is radical and will cause personal and economic hardship (click here); but it is necessary. Modeling suggests that at the current rate of infection Ontario will have 300 COVID-19 patients in ICUs by the end of December and up to 700 by the end of January! 700 ICU admission would be unsustainable and would threaten our ability to provide care for critically ill patients.

DR Kieran Moore with a flip chart illustrating how virus is spread

Not unlike Charles Dickens’ The Christmas Carol our future is subject to change by our behaviour. Dr. Kieran Moore, Head of KFL&A Public Health is quoted as saying, “I would support our politicians, if they were to lobby for us to have a two-week lockdown period,” he said on Tuesday, Dec. 22, 2020. He suggested local data could be reassessed after that. “If our numbers are going down, if we have good hospital bed capacity… I think we could be allowed 14 days.” (click here). Let’s follow the plan for the next 2 weeks and see if we can end our lockdown earlier-fingers crossed…

2) Update on major outbreak of COVID-19 at Joyceville Institution and Collins Bay (click here): Eighty-nine inmates and five staff members have been diagnosed with COVID-19 at the Joyceville Institution since the outbreak was declared on Thursday, Dec. 17 (click here). The good news is that there have been no new cases in the past 24 hours in the Federal system and no new patients have been transferred to KGH. Likewise there are no new cases in the provincial prison system. We may not be out of the woods but this news is encouraging.

3) KFL&A turns orange (but some good news) (see update from KFL&A Public Health): As of noon today our region moved to the orange category (although this colour code system is superseded by the province wide lockdown). The total number of cases in KFL&A since the pandemic began is now 497, 11 more cases since my note last Thursday (not counting the prison outbreak). There are now 80 active cases in KFL&A, decreased from 115 cases last Thursday. There are 3 COVID-19 patients hospitalized at KGH and 3 hospitalized in Hasting Prince Edwards county. There are now 182 active cases in South Eastern Ontario down from 226 on December 17 in all of South Eastern Ontario. The rate of positive COVID-19 tests is also decreasing (and is 1.2%). In the last 2 days 1850 tests were done and 24 tests were positive Thus the curve is flattening in KFL&A and the lockdown will likely quash the second wave.

table and graphs showing kfl&a covid data

The cases we are seeing relate to ripples from the recent outbreaks, including 15 cases in an unidentified place of worship (click here), the third day Worship Center (click here) the Chevrolet-Cadillac dealership in Gananoque (click here), and multiple Queen’s University-related, off campus, house parties (click here).

The city is now charging people in violation of public health regulations (click here). A CTV report indicates the City of Kingston’s bylaw officers filed 31 charges under the Reopening Ontario Act related to indoor social gatherings of more than 10 people. Each Part 3 Summons under the Reopening Act includes a minimum $10,000 fine upon a conviction. Individuals who received the Part 3 Summons will need to appear before a Justice of the Peace in the new year.” (click here).

Bottom line: The vaccine will protect us; however, it will take months to get a critical mass of Canadians vaccinated. Meanwhile we have to rely on good public health practices (as outlined by provincial lockdown).

4) Moderna vaccine approved today (click here)

Health Canada has approved the Moderna vaccine today and deliveries of the first set of doses will begin asap (i.e. before January). Prime Minister Justin Trudeau has said Canada will receive up to 168,000 doses of the vaccine this month, with deliveries beginning within the next 2 days. This is great news since the Moderna vaccine is as effective as the Pfizer vaccine but is easier to store due to less rigorous refrigeration requirements. This will make it easier to distribute. We anticipate receiving 40 million doses over the coming year.

5) Current vaccines work against the new strain of SARS-CoV-2 emerges in England (click here)

After we all took a deep breath of relief with the arrival of vaccines there was a feeling of being punched in the gut with announcement of a new viral strain in the UK (see my Monday note). Would this new variant of SARS-CoV-2 elude the vaccines? Here is the initial evidence: the answer is a resounding NO! This is good news and shows the vaccine should work perfectly well on the new viral mutant.

These preliminary data (peer review pending) used the serum from vaccinated patients to neutralize with regular (WT) version of the COVID-19 virus (SARS-CoV-2) versus the new variant/mutant that has emerged in England (N501Y). The graph shows the vaccine elicited antibodies work equally well for both the old strain and the new! Good news.

I am reposting the answers to FAQs re: the new COVID-19 variant, based on a new posting by Rambaut A et al from the ARTIC group (click here):

1) Are viral mutations always dangerous? No, many viral mutations do not increase or alter infectiousness or disease severity. In an excellent article in The Conversation, Dr. Lucy van Dorp notes, There are many thousands of lineages of SARS-CoV-2 which differ on average by only a small number of defining mutations. These variants are useful to track the virus but do not cause more severe disease.

2) Is the new viral strain more lethal? There is no evidence for increased lethality or disease severity thus far.

3) What evolutionary processes or selective pressures might have given rise to the new variant (lineage B.1.1.7)? Rambaut et al note that immunosuppressed people often retain SARS-CoV-2 for prolonged periods of time and often receive numerous therapies, including antibody therapy. This may provide the circumstances for spontaneous mutations to accumulate. They note that viruses from immunosuppressed patients are more like than others to have numerous significant mutations. They propose that natural selection, arising from antibody therapy that immunosuppressed patients often receive, may accelerate mutation rates. This remains a theory.

6) Ontario has had 162,663 COVID-19 cases with 2408 new cases since yesterday, a 4.8% positivity test rate and 1002 people in hospital (click here): It is very concerning that we are now consistently over 2000 new cases of COVID-19 per day and the viral R0 (its reproductive value) is over 1.0-meaning every 1 case generates 1.02 new cases (a recipe for growth of the infection in society).

table showing overview of Ontario covid cases

Ontario’s pandemic at a glance December 23rd (click here)

Ontario’s provincial rate is 1094/100,000 population, double the rate in November and is now almost 6X higher than in KFL&A (224.7 cases/100,000 population). In KFL&A our prevalence has increased 4X since the summer! There were 2408 new cases in Ontario today (click here). The rate of positive SARS-CoV-2 tests today is high at 4.8% (click here). COVID-19’s large second wave in Ontario is resulting in rising rates of hospitalizations (1002 today in total), most on Medicine wards (gold below) and the balance, 275, in ICU (black line in graph below).

graph showing increase in hospitalizations and ICU patients during 2nd wave

Peel (on Toronto’s western border) remains the hot spot in Ontario with 2235.4 cases/100,000 population. Toronto’s prevalence remains high at (1701.9 cases/100,000 population, more than double the rate 2-weeks ago (711 cases/100,000) and ~8 times higher than Kingston) (see map below). Windsor (1470.5 cases/100,000 population) and Ottawa (895.6 cases/100,000 population) remain hotspots. Eastern Ontario, around Cornwall, has also passed the 500 cases/100,000 population mark since last Thursday (578.8 cases/100,000).

Neighborhood variation in COVID-19 in Toronto: Most of Toronto’s neighbourhoods are COVID-19 hotspots and have a cumulative prevalence of over 1000 cases/100,000 population (click here).

toronto waterfront and skyline with cn tower

Toronto remains a collection of neighbourhoods with vastly different COVID-19 realities due to differences in social/economic, racial and health circumstances. Although COVID-19 is increasing in the city as a whole, case load is widely variable amongst Toronto neighbourhoods. We should avoid travel to and from these hot spots from lower prevalence areas, like Kingston.

Since the pandemic began the Thistletown-Beaumond neighbourhood has had 5347 cases/100,000 residents, roughly 11X the burden of COVID-19 in the more affluent Beaches neighbourhood (482 cases of COVID-19/100,000 residents).

When one examines recent cases (i.e. those diagnosed since Nov 27th), case prevalence is still concerning-ranging from 32 cases/100,000 residents in Woodbine Corridor to 1,185 cases/100,000 residents, in Englemount-Lawrence.

6) Canada’s second wave of COVID-19: We have crossed the half million case mark with 526,371 total cases to date, with 75,117 active cases (click here): We have had 526,371 cases of COVID-19 in Canada since the pandemic began (see below). 83.1% of all cases to date have recovered. There has been a ~2.8% mortality rate amongst people diagnosed with COVID-19. Most cases of COVID-19 in Canada have been (in descending order), in Quebec, Ontario, Alberta and BC. Canada has done ~15.3 million COVID-19 tests and has a cumulative test rate positivity (since the pandemic began) of 3.41%. Ontario remains the province with the most testing (7.4 million tests, 2.18% cumulative positive rate).

COVID-19 second wave sees a marked rise in hospitalizations-Dec 23rd^h 2020

Rates of infection are high in all Western provinces (BC to Manitoba) but with introduction of more aggressive public health measures these provinces are now all plateaued (which is the intended outcome of the Dec 26^th Ontario lockdown). Rates of new infection are low in all Maritime provinces, although highest in New Brunswick. There are outbreaks in the North in indigenous communities in Nunavut (click here). The rates in Nunavut are fortunately declining rapidly.

8) The COVID-19 global pandemic has seen 1,725,057 million deaths and 78.4 million cases (click here): There are now 78,420,543 million cases globally. There have been 1,725,057 deaths. The number of cases has increased almost 5-fold since the beginning of August, 2020, when there were 16,296,790 cases globally. The pandemic hot spots are in the USA, India, Brazil, and Russia (click here). A bit of a bright note is that the graph showing daily cases (bottom right) is beginning to plateau.

world map and ranking of countries with over 300,000 cases

Global COVID-19 burden continues to accelerate: Dec 23rd 2020

The USA with 18,348,619 cases and 324,674 deaths tops the COVID-19 list and accounts for ~23.2% of the global pandemic (up from 21% 2 weeks ago), while the USA only accounts for ~4% of the world’s population (see below). The COVID-19 active case map (above) shows the high incidence of infection in the US and the western half of South America, Brazil as well as in Europe (the bigger the salmon-colored dot the higher the incidence-cases/100,000 population). The ONLY solutions to this are adherence to public health measures and rapid, mass vaccination.

USA positive test rates (click here): In contrast with Ontario’s ~4.8% rate of positive tests, the USA has an average positive test rate of 11.2% (click here). Ontario’s rising rate of positive tests is similar to rates in a number of states (like Massachusetts at 5.4%). However, rates of positive testing in the USA are extremely variable by state (as are public health policies!). Illinois and New Jersey have positive test rates of 7.4 and 6.0%, respectively whilst South Dakota remains at a staggering 36.9% today in (down from 50% 2 weeks ago). The US-Canadian border will remain closed for routine travel at least until the December 21, 2020 and, for other countries, borders remain closed until Jan 21^st 2021 (click here). That said, Canadians can still fly to America (although certain rules apply) and as discussed in my note 2 weeks ago, Canadian citizens can return to Canada from America, with a number of requirements, including quarantine) (click here).

directional traffic signs at Canadian USA border

Regular reminders

KHSC bed capacity and preservation of elective care despite lock down: Bed capacity at KHSC has increased to 112 beds available (versus 99 beds on Monday) (see below). Ventilator capacity (46) also remains good. Our ICU capacity remains extremely limited (by non-COVID-19 cases). On the bright side even with the provincial lockdown we are only reducing elective care to the smallest extent required, ensuring we provide care to the 99% of patients who do not have COVID-19. We recognize that the term “elective care” is really a misnomer-many of these “elective” patients have cancer and other serious disease which will not tolerate delay in care. We are not reducing cardiac work, as just one example, as much of this work is urgent and delay would be life threatening. We are encouraging physicians to optimize the use of e-health visits. We are also reminding patients who are coming to clinics in person that unless it is essential (and approved) they need to come alone, to minimize crowding in our clinic waiting areas. That said, it remains VERY safe to attend appointments at our clinics or to come to hospital for needed care!

chart and graph showing bed capacity at KGH

KHSC has limited ICU capacity but more general bed capacity-Dec 23rd^st 2021

Use the Mobile Screening Tool to expedite clinic visits: Complete the COVID-19 pre-screening tool here and you will be able to “skip the line”: One way to safely expedite entry of patients into our facilities is to have all patients complete our pre-screening questionnaire before their clinic visit. This will screen out people who are sick and expedite entry to the facility for everyone. Reducing lines waiting to enter the clinics will be particularly important as colder weather arrives. The mobile screening tool 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. 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. All details on the policy can be found using this link (click here).

COVID-19 testing at Beechgrove Community Assessment Center: (click here): All COVID-19 test must be scheduled appointments (versus walk in). Appointments can be scheduled using our on line scheduling system. Before booking a test, individuals should complete the online tool to determine whether they qualify for testing (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. To be tested you will require: A valid Ontario health card or a piece of photo identification. You must also wear a mask and maintain physical distancing at all times while in the walk-in line (click here).

photo of female getting nasal covid 19 swab transparency showing how far the swab goes in

Because health care workers (doctors and staff) are increasingly having to miss work because their children have been sent home from school or daycare with symptoms of a upper respiratory tract infection, we have arranged that their children can access expedited testing at Beechgrove . The goal of this service is simply to allow the healthcare worker to return to work as quickly as possible for the public good. The children of staff will be tested between 1230 -1300 by appointment, 7 days/week. The new program for families applies to children up to age 18, an includes children of staff and physicians who provide clinical care and service. Staff and physicians themselves should contact occupational health to book their testing appointment. To book an appointment for a child, KHSC staff should call 613-548-2376. Testing of clinical staff and faculty and their children is processed at the KHSC lab with an average turnaround time of less than 24 hours.

Increased outbreaks and deaths in Long Term Care facilities (LTC): 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 2555 deaths in nursing homes (up 47 cases from Monday) account for ~60% of all deaths in Ontario, click here. There are ~ 960 active cases in LTC residents and a similar number of active cases in LTC staff! In the last month the rate of death amongst LTC residents continues to increase daily and is now >50/week! Outbreaks in nursing homes usually start with a person in the community (health worker or family) acquiring the infection and importing it into the facility. Thus, protecting LTCs is best done with a combination of reducing community spread of COVID-19 and ensuring single occupancy rooms in LTCs (as well as appropriate pay for PWS workers, provision of PPE and rapid testing capacity). To this advice we now happily add the early vaccination of support staff in these facilities!

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 (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.

Children are usually infected by an adult, usually in their home, rather than by other children. No data updates are available today. On Monday the number of cases in school age children (which includes teenagers) has increased dramatically to 5103 up from 3570 case 2-weeks ago and ~5 times the number from ~ 1 month ago (985 cases). Approximately 20% of schools in Ontario have at least one confirmed case (table below).

Amongst younger children and toddlers COVID-19 remains relatively rare. In Ontario’s 5,500 licensed child care centres and over 120 licensed home child care agencies there is a very low COVID-19 burden (see table). The rise in cases has been modest in these young children. 696 toddler age children have now been infected to date, up from 508 cases 2 weeks ago. Approximately 4.5% of day care centers have a confirmed case (table below).

KHSC’s screening questions effect visitors and health care workers differently: an introduction to “workplace isolation” for health care workers.

Although COVID-19 has increased in frequency in our region we are still relatively low compared to Ottawa, Toronto, Peel, Windsor or America. Ideally, one should avoid travel to and from these regions. However, life is not always so simple. For example, many of our trainees and staff live in a red zone and commute to work. When it comes to COVID-19 entering our region it is usually imported by a traveler from a high prevalence area (red zone). Likewise for hospitals, COVID-19 infections are almost always acquired in the community and brought into hospitals (not vice versa)! Thus, we must be vigilant about keeping COVID-19 out of the hospital. Consequently, KHSC is implementing new screening questions about travel to and visitors from Red Zones. This question also applies to visitors from outside Canada. The consequences of failing screening (i.e. answering “yes” to the question about travel to and from the red zone or red zone visitors) is understandably different for visitors (who are not essential to running a hospital) versus health care workers (who are needed to keep the hospital running).

Visitors that fail the screening question: If a visitor answers positively (i.e. they have been to a red zone or been visited by a red zone resident) they will not be allowed to enter KHSC facilities.

KHSC screening questions regarding red/gray zone travel

Healthcare workers that fail the screening question (assuming they are asymptomatic):

Health workers who are essential and fail the screening questions because they have been to a red zone or live in a red zone, but who are otherwise well, usually with no known COVID-19 exposure, will be reviewed by occupational health and may be permitted to work under our workplace isolation policy. If Occ Health deems you to be safe to work you will be placed on “work isolation”. In this case you must:

stay on work isolation for 14 days after your last exposure to the COVID-19 risk or confirmed positive case; (unless Occupational Health has informed you otherwise) OR
stay on work isolation until your close contact/household contact with acute respiratory symptoms is confirmed negative for COVID-19

Work isolation requires you to:

Wear a procedure maskat all times when in the workplace along with any additional PPE as indicated by your Point of Care Risk Assessment (POCRA).
Self-monitor for the development of symptoms and take your temperature twice daily.
Do not eat your meals in a shared space or remove your mask in the presence of others.
Where you have removed your mask to eat, use a disinfectant wipe to clean any surfaces you were in close contact with.
Work in only one facility.
Identify yourself as being on “work isolation” at the staff screening station.
If you are a “high risk” close contact of a person who is positive for COVID-19:
you are also required to self-isolate when outside of the workplace; and
travel to and from work in your private vehicle but if you must take public transit, wear a procedure mask and perform hand hygiene before/after travel to work.
Should you develop symptoms while at work, you must promptly remove yourself from providing care/working, and contact your manager/supervisor and Occupational Health Safety & Wellness (OHSW) (KGH site x4389; HDH site x2265)
For more information on How to self-isolate while working, for health care workers(click here). For information of how to isolate at home for all others (click here).

9) Holiday fun: Cross Words for COVID-19

loaf of fruit case on wooden board with slice cut

By now you’re all experts on COVID-19, quarantines, masks and have more knowledge of virology and epidemiology that you ever wished to have! Here is an excerpt from my family's annual Christmas card. Cross Words for COVID-19 will give you the chance to check your expertise. The puzzle is best challenged whilst armed with fortified egg-nog and fruitcake (apologies to Dr. Evans). Answers on the next page.

Answers

A thought for the holidays to all staff, trainees, volunteers and faculty: What you have done this year is remarkable. 2020 has been exhausting but there is hope, realistic hope, for an end to this pandemic in 2021. I’m proud to have worked alongside you as we cared for patients, taught the next generation of learners and performed research to better humankind. The pandemic has required persistence, commitment, hard work, flexibility and courage. It’s challenging to work day in day, day out with masks, goggles and gloves! You have each risen to the challenge. Through your efforts our hospital, Postgraduate Medical programs, Medical school, allied health training programs and more are working and serving society! This holiday season, I encourage you to give yourself a virtual pat on the back. You made it through 2020 and made contributions to healthcare, education and research that you will be rightfully proud of for the rest of your life. KUDOS (and Happy Holidays).

Stay well!