December 3, 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

| 3 December 2020

1) Which Canadians get the COVID-19 vaccine first? (click here)

2) Ontario has had 121,746 cases with 1824 new cases since yesterday, a total of 14,795 active cases and 666 people in hospital (click here):

3) COVID-19 volumes continue to increase in KFL&A although we remain in YELLOW status (see update from KFL& A Public Health)

4) Canada’s second wave of COVID-19: 391,600 total cases, a rapid spike in infection in western Canada and Nunavut (click here):

5) The COVID-19 global pandemic has seen ~1.45 million deaths and 64.7 million cases, up 2 million since Monday (click here):

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).

1) Which Canadians get the COVID-19 vaccine first? (click here)

Health Canada will soon be reviewing the safety of COVID-19 vaccines from Pfizer and Moderna. The question is who will get the first, limited supply of the vaccine. Canada’s National Advisory Committee on Immunization has devised a priority list identifying which groups of people will be first to be offered of the COVID-19 vaccine. Their recommendations are based on the risk of serious illness or death, and risk of exposure or outbreaks. Choosing who goes first wisely is important because Canada is only likely to get enough vaccine for 3 million people between January and March.

Candidate populations to go to the front of the vaccine queue include:

o Older Canadians: There are 400,000 people in LTCs and 7 million Canadians over the age of 65 years.

o People with pre-existing conditions like heart disease and people who live with them

o Long-term care workers

o People who live in Indigenous communities

o Front-line essential workers such as first responders or grocery store employees

So, who won’t get vaccinated in the first round? Most children and most health young people will have to wait until the second half of 2021.

Nonetheless, a bigger question than “Who is first” is “Who will agree to be vaccinated”? A big concern is the anti Vax group, many of whom are unidentified. These people may not say much but privately they do not intend to participate, largely because of ignorance, inflamed by pseudoscience. Even amongst KHSC staff our influenza vaccination rate is only ~60%. The other 40% of faculty and staff obviously have reasons for not being vaccinated. Hopefully many were vaccinated privately and may not be recorded in our 60% corporate vaccine count. I will be vaccinated as soon as the vaccine is available to me. I am confident because I know that prior to vaccination the vaccine will have passed through a rigorous clinical trial, the results of which will have been scrutinized not only by Health Canada but also by other regulatory agencies, including the Food and Drug administration in the USA. In addition, the 2 vaccines Canada will get first are also unique mRNA vaccines in that they contain no virus and no viral particles (i.e. they cannot cause a mild form of the disease).

Britain approved the Pfizer vaccine on Wednesday this week and will be the first country to have vaccination begin, starting next week. The vaccine was granted emergency authorization in the UK by its independent regulator, the Medicines and Healthcare products Regulatory Agency (click here) on Wednesday. Britons will be first to have vaccines in arms first because of their very dynamic approval process, which dealt with clinical trial data in a more real-time manner than was done in Canada or the USA, allowing an earlier decision by their regulatory agency. In Britain they are prioritizing vaccination of nursing homes residents and the elderly. Their Joint Committee on Vaccination and Immunization (JCVI) has recommended that nursing home residents and staff are vaccinated first. After this group they propose vaccination proceed according to age, starting with people older than 80, as well as frontline health workers (click here). Age will then continue to be the deciding factor, with older adults vaccinated down to those older than 50.

What is happening abroad? In the USA they will have 20 million doses of vaccine available by the end of 2020 (assuming the FDA approve the Pfizer and Moderna vaccines, FDA hearings on Dec 10 and 17th). The first shipments of Pfizer's coronavirus vaccine will be delivered on December 15, if the FDA grants emergency authorization. Healthcare workers and nursing home residents are first in line for the vaccines (click here). Of course, with the outgoing president’s predilection to induce chaos it is possible vaccine distribution will devolve to state choice and other priorities may emerge.

In the end the COVID-19 pandemic has laid bare all of humankind’s flaws: inequity, lack of social justice, racism and ignorance. Fortunately our species does have some counterbalancing virtues, including intelligence, ambition and in many cases altruism. Let’s use these virtues and work together, with our actions guided by facts and reliable information, to ensure that when our turn comes we get vaccinated! It’s good for us individually and for Canadian society. It is really the only way the economy and the borders will reopen. Remember, vaccines are the main/only reason we don’t have small pox and vaccines are why children don’t suffer from measles, mumps and rubella. Vaccines reduce or eliminate shingles and prevent meningitis. Vaccines prevent cervical cancer. They do all these good things safely and cheaply. It is reassuring for all that the COVID-19 vaccines will only be approved and offered to Canadians if they are objectively safe and demonstrably effective in large clinical trials. Because countries, like Britain and the USA, will be ahead of us there will be valuable practical real world safety data for us to learn from. This will hopefully reassure those who are open to vaccination but fearful/anxious. If we can vaccinate over 70% of the population we will also indirectly benefit vulnerable people by inducing societal herd immunity.

Dr Tam at press conference sitting at panel with mic and cdn flag behind her

2) Ontario’s has had 121,746 cases with 1824 new cases since yesterday, a total of 14,795 active cases and 666 people in hospital (click here):

Ontario’s pandemic at a glance December 3rd (click here)

There were 1824 new cases today, up +1.5% from yesterday (click here). There have been 7601 hospitalizations, and 3712 deaths in Ontario, since the pandemic began (up 6.2% and 3.0% since yesterday, respectively). On a positive note the SARS-CoV-2 reproduction number (number of people an infected person will infect) is down below 1.0, which if sustained would lead to a fall in cases and a flattening of the curve. The rate of positive SARS-CoV-2 tests in Ontario since the pandemic began is 1.89% but remains high at 4.4% today (although this is down from a peak of 5% ~2 weeks ago) (click here).

Ontario’s provincial rate (819/100,000 population) has doubled in the past month and is now almost 6X higher than in KFL&A (124.6 cases/100,000 population). However, for those following the local pandemic our prevalence has doubled since the summer!

Peel (on Toronto’s western border) is the hot spot in Ontario with 1672.3 cases/100,000 population. Toronto’s prevalence remains high at (1322.3 cases/100,000 population, up from 711 cases/100,000 population 2-weeks ago and ~10 times higher than Kingston) (see map below). Ottawa is also a hot spot at 816 cases/100,000 population (click here).

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 skyline with clouds and 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 very high in some Toronto neighbourhoods. For example, Maple Leaf (highlighted on the map below) has had 4203 cases/100,000 residents, roughly 12X the burden of COVID-19 in the more affluent Beachesneighbourhood (334 cases of COVID-19/100,000 residents). When one examines recent cases (i.e. those diagnosed since Nov 4th), case prevalence is lower-although still concerning-ranging from 42 cases/100,000 residents in the Beaches to 1274 cases/100,000 residents, in Thistletown-Beaumont Heights.

3) COVID-19 volumes have increased in KFL&A but we remain in YELLOW status (see update from KFL& A Public Health): There have been 10 new cases in the region since my note on Monday. There are 31 active cases in the region, up from 16 one week ago. There are now 89 active cases in southeastern Ontario, the highest number since the pandemic began. There is only 1 person hospitalized in southeastern Ontario and that person is in Lennox, Leeds Greenville. The total number of cases since the pandemic began is now 272. All local COVID-19 patients are recovering in the community and there are no inpatients in KGH (see update from KFL& A Public Health).

In the past 3 days our lab has done 2079 test. There were 18 positive tests, including 11 from Kwartha area, 3 from Lennox, Leeds Greenville and 4 from KFL&A. Extendicare in Kingston has an outbreak due to 1 infected staff member (click here). Because the local disease prevalence is up, we anticipate adding screening questions regarding travel to red zones and lock down zones next week. If you traveled to such a region its likely health care workers have to undergo workplace isolation-stay tuned next week.

There were 2 infected staff members at KGH last week. These individuals we identified early and all patient and staff contacts traced. To date no infections have resulted from their exposure to others in KGH. The individuals acquired their infections in the community-a reminder that our hospital is a very safe environment which to work and to receive care!

KFL&A Dec 3rd 2020

4) Canada’s second wave of COVID-19: 391,600 total cases, a rapid spike in infection in western Canada and Nunavut (click here): We have had 391,600cases of COVID-19 in Canada and 12,339 deaths (see below) since the pandemic began. There are 66,940 active cases in Canada today and ~80% of all cases in the pandemic to date are recovered. There has been a ~3% 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 13.234,020 million tests and has a cumulative test rate positivity (since the pandemic began) of 2.95%. Ontario remains the province with the most testing (6.3 million tests, 1.89% cumulative positive rate).

graphs and table of current covid data in Canada

COVID-19 in Canada December 3rd 2020.

Rates of infection are rapidly rising in all Western provinces (BC to Manitoba) whereas they are rising more slowly) in Quebec and Ontario. Rates of new infection are low in all Maritime provinces, although highest in New Brunswick. There are new outbreaks in the North in indigenous communities in Nunavut (click here), which is very concerning given their very limited health care resources. Although Quebec still has a higher rate of test positivity than Ontario, its rate of case increase is flat and the total number of cases it accounts for, while still the greatest in Canada, is being approached by Ontario and Alberta (see graph below) (click here)

5) The COVID-19 global pandemic has seen ~1.45 million deaths and 64.7 million cases, up 2 million since Monday (click here): There are now 64,723,945 cases globally and there have been 1,497,093 deaths. The number of cases has increased 4-fold 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).

The USA with 13,943,627 cases and 273,920 deaths tops the COVID-19 list and accounts for ~21% of the global pandemic, while the USA only accounts for ~4% of the world’s population (see below).

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

USA positive test rates (click here): In contrast with Ontario’s ~4% rate of positive tests, the USA has an average rate of positive COVID-19 tests of 10.5% (a rise in rates since the Thanksgiving weekend) (click here). This is a reminder of what happens when groups assemble without attention to public health measures, like masking, distancing and assembly only in small groups.

graph showing bump in cases post American thanksgiving

A post-Thanksgiving bump in the rate of positive tests in America

Rates of positive testing remain a staggering 43% today in South Dakota and over 23% in Arizona. 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 21st 2021 (click here). That said, Canadians can still fly to America (although certain rules apply) and as discussed in my note last week, Canadian citizens can return to Canada from America, with a number of requirements, including quarantine) (click here).

driving directional signs at Port Huron Canada USA border

Regular reminders

KHSC bed capacity: Bed capacity at KHSC is reasonably good (89 beds available) (see below). Ventilator capacity also remains good. Elective care including procedures and outpatient clinics continues. It remains very safe to come to our hospital and clinics and I encourage patients to advocate for themselves to get the healthcare they need!

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.

screenshot of prescreening tool for KHSC

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). Our online system, Coconut, launched today and will assist in contact tracing. Appointments can be scheduled by telephone or by our new Eventbrite 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.

animated nasal covid swab showing where the swab goes once inside nasal cavity

three young boys dressed up like doctors

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 2253 deaths in nursing homes (up 30 cases from Monday) account for ~62.0% of all deaths in Ontario, click here. In the last month the rate of death amongst LTC residents continues to increase daily! 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).

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. The number of cases in school age children (which includes teenagers) has increased dramatically to 3330 up substantially from 2855 Monday and triple the number from 3 weeks ago (985 cases).

Amongst younger children and toddlers COVID-19 remains relatively rare. In Ontario’s 5,500 licensed childcare centres and over 120 licensed home childcare agencies there is a very low COVID-19 burden (see table ). The rise in cases has been modest in these young children. 468 toddler age children have now been infected to date, up from 317 cases 2 weeks ago.

Stay well!

December 3, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

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December 3, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program