All patients admitted to KHSC will undergo Covid-19 testing
1) Global progress in COVID-19 vaccination- Canada gets a “C” for vaccine delivery but an “A” for public health measures!
2) All about COVID-19 Vaccines:
- Perspective-the rush to vaccinate prior to spread of variant virus and the need to take a global approach to vaccination (how equity serves safety).
- Updated FAQs about vaccination effectiveness against viral variants and safety of vaccination for people on blood thinners, with allergies or people who are immunosuppressed
3) Ontario’s epidemic is much better controlled since the lockdown with rates of new cases below 1500/day (1265 new cases yesterday and only 901 people in hospital)-but we now have cases with all 3 variant viruses (UK, Brazilian and South African) (click here).
4) KFL&A COVID-19 rates remain amongst the lowest in the province (see update from KFL& A Public Health)
5) Canada’s COVID-19 epidemic continues to improve: There have been 804,263 total cases to date with 3,203 new cases yesterday and resolution of 89.7% of cases. There are decreases in active cases (-17%) and hospitalizations (-15%) and deaths (-22%) (click here) (click here).
6) The COVID-19 global pandemic: There have been 106,246,361 cases and 2,319,104 deaths since the pandemic began. Active case rates are declining (click here) and positive test rates in the USA have declined to levels last seen in July 2020.
7) Improvement in COVID-19 in Ontario’s Long Term Care facilities (LTC):
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1) Global progress in COVID-19 vaccination- Canada gets a C for vaccine delivery but an A for public health measures! The graph below offers a snapshot on how we are doing globally in administering vaccine (presented as # of vaccines administered/100 people/country). The United Arab Emirates is doing the best and Canada is well down the pack (click here). Canada’s problem at the moment is lack of supply-there have been few vaccines to give. Hopefully as vaccines arrive this month we will demonstrate our ability to rapidly distribute vaccines. This will require innovative means of vaccination like drive through clinics and large vaccine centres (arenas etc.). We will no doubt move from current quibbles about who goes first to a national effort to get vaccines in all willing arms in the shortest time possible (before more novel viral variants emerge).
Global vaccine progress, Feb 8th 2021
In this regard, America has shown tremendous progress and is vaccinating 1.4 million people per day (see below)! Canada would do well to set (and meet) such an aggressive standard itself.
America mobilizes to vaccinate its public-Feb 8th 2021
It is noteworthy however, that recent declines in rates of COVID-19 in Canada have little to do with vaccines and a lot to do with increased public health measures. Compare Israel (with a massive vaccination rollout but a plateau in new case rates-see below) to Canada (with massive public health interventions but only a modest vaccine rollout).
Israel continues to have a lot of new cases despite vaccines
This does not mean vaccines don’t work; it is just that even in Israel there remain a majority of nonvaccinated, susceptible, people (who can only be protected by adhering to public health measures until vaccinated). In Canada we get a “C” for our vaccination rates but an “A” for adherence to public health measures. Interestingly, it is clear that, despite the pain of rolling provincial lockdowns, we have benefited from a big fall in new infection rates (22% this past week and similar falls the week before), see below(click here). That said, we will need vaccination to sustain the lower infection rates as we reopen our provinces.
Canada’s disappointing vaccination roll-out update (click here): Canada’s roll out of vaccine has been slow. If there is a lesson to be learned from this it is that Canada cannot rely on the rest of the world to produce its medicines and vaccines. We have a national complacency, perhaps having come to rely on the USA for industry and China for materials. The pandemic has made it clear that whether its PPE or vaccines we are dependent on a supply chain that we don’t control. Canada needs to learn from this and take a “never again” approach going forward. We need to fund science and support national industry or risk further decline not only in our stature as a nation but in our peoples’ health security.
Only 1,253,140 doses of COVID-19 vaccines (including both Moderna and Pfizer-BioNTech) have been delivered. Thus far, 86% of delivered doses have been administered. 900,713 Canadians have received at least one dose of an approved COVID-19 vaccine (see below). At least 176,584 Canadians are fully vaccinated (only 23,000 more than Monday)(click here). The priority population for first vaccines in Ontario has been the residents and staff of long term care (LTC) facilities. Both Toronto and Ottawa have completed vaccination of all LTC residents who agreed to be vaccinated (click here). Approximately 3,000 residents have refused the first dose(click here). This program of vaccination is working and is moving the dial in Ontario’s LTCs-See item 7.
Number of vaccinations in arms as of Feb 8th 2021
Based on the clinical trials and experience in millions of people who have been vaccinated world-wide we can be reassured of vaccine safety and efficacy. All the side effects (called adverse events and abbreviated AEFI) are tracked and reported by the government of Canada. Here is what we have seen to date (updated Jan 29th, 2021) (click here).
COVID-19 vaccines are safe-data from Canada up to Jan 29th 2021: most adverse events were in those 18-50 years of age and there were no deaths
2) All about COVID-19 Vaccines:
- Perspective-the urgency of vaccinating prior to spread of variant virus and the need to take a global approach to vaccination (how equity serves safety).
- Updated FAQs about vaccination effectiveness against viral variants and safety of vaccination for people on blood thinners, with allergies or people who are immunosuppressed
Perspective on why we need to act globally: Rich countries have vaccines; poor countries do not. In Canada we are understandably frustrated in by the slow vaccine rollout; but we can be fairly confident that we will be vaccinated sometime this year. People in low income countries are not so fortunate. This is unacceptable for several reasons, one related to social justice and the other to the nature of viral infections.
Let’s begin at home. Canada is appropriately under pressure to vaccinate its residents not just to save lives and allow reopening of society. There is also time sensitivity, because the longer the with the majority of people still susceptible to the virus the more damage the new highly infectious viral variants (mutants) can do. The risk to a large number of vulnerable Canadians of the rapidly evolving and mutating SARS-CoV-2 is real.Just in the last week or two there is yet a new mutation of the already mutated “British variant” of the virus. This new mutation is called E484K, and this mutation is also found in the highly contagious Brazilian and South African variants (click here). The mutation makes it easier for the virus to bind to human cells and evade antibodies. These mutations don’t defeat the vaccine but it does reduce vaccine effectives a bit.
The South African variant has three or more mutations and is more resistant to existing vaccines than the original SARS-CoV-2. Early reports related to the newer vaccines from Novavax and Johnson & Johnson, reportedly show less effectiveness against these mutant viruses. Novavax says its vaccine is 89.3% effective overall in the UK. Their study included 50% of people infected with the UK variant virus (click here). Whilst the vaccine was 95.6% effective against the original COVID-19 strain it was only 85.6% effective against the UK variant strain. This vaccine is also effective against the South African variant, however once again less so than against the original coronavirus, offering only 60% protection in a population where most infections were caused by the South African mutation variant (unpublished data (click here).
Also in unpublished data, Johnson & Johnson said the level of protection of its new vaccine is 72% in the United States, 66% in Latin America and 57% in South Africa (click here). These effectiveness numbers sound low but it there is some good news from the Phase 3 ENSEMBLE trial (conducted in eight countries across three continents including 34% (N= 14,672) of participants over age 60). The study shows that the J&J vaccine offers complete protection against hospitalization and deaths, 28 days post-vaccination (click here). So, while there may still be risk of infection the vaccine it eliminates the really bad infections!
The longer we leave populations unvaccinated the more chance the virus has to acquire mutations, many of which will increase its infectivity or lethality. The virus doesn’t care if these unvaccinated people are rich or poor! If we could mass vaccinate globally viral spread would stop and with it mutation generation. This would quickly end the pandemic.
But will rich countries share vaccine? In a recent Nature paper, Canada doesn’t look great in this regard. We have more secured vaccine per person than any other country (click here).
Canada has done well to secure vaccines-it will do well to share them!
The article notes, “Low- and middle-income countries are let to rely on on contributions from COVAX, a joint fund for equitable distribution of COVID-19 vaccines led by Gavi, a funder of vaccines for low-income countries based in Geneva, Switzerland, the World Health Organization, and the Coalition for Epidemic Preparedness Innovations (CEPI) in Oslo” (click here). They have secured 700 million vaccine doses so far and want to provide 2 billion by the end of 2021. They have the goal of supplying 20% of the population of participating countries. More than 189 countries have signed up to COVAX, including wealthy economies that have joined to subsidize vaccine access.”
However, even if they reach this goal (which depends on wealthy countries) this leaves many people unvaccinated. In addition to compassion for our fellow humans, this represents a problem. As long as large groups of people (billions) are unvaccinated the virus can thrive and mutate. Ultimately our own greed/apathy would come back to bite us as these future mutants might well evade vaccines and reinfect people in rich countries.
So, we need to do right by all people. Canada has recently drawn criticism by being the first country to use some of the vaccine it had offered to COVAX for our own domestic use (done because our domestic supply chain was disrupted) (click here). Once we get our momentum in domestic vaccination we need to share our (anticipated) vaccine wealth; not for charity, nor for praise, but because it is both ethical and a part of the solution to end the pandemic.
Here are answers to some updated FAQs with answers to common questions about the COVID-19 vaccines.
FAQ 1) Does the vaccine work against new variants (mutations) in the SARS-CoV2 virus? Short answer is a qualified YES. The vaccines work albeit not quite as well for the variants. This slide below (from Dr Evans) shows results from 144,000 participants in randomized clinical trials (RCTs, including both the vaccinated and the unvaccinated). In those receiving any active vaccine there there are only 3 cases of severe COVID-19 (vs 37 in the control group). There were no deaths in people who were vaccinated with any of the vaccines versus 5 deaths in the control group. As discussed at the beginning of this section, even though absolute protection is slightly less for UK and South African variants the vaccines have a preserved ability to prevent serious adverse outcomes (like hospitalization and death). Thus, despite variant viruses the vaccines are lifesavers!
Update: It was recently reported that South Africa has decided not to roll-out the Astra Zeneca vaccine because it may be ineffective against the South African variant of the virus (click here). However, it appears this decision is based on a very small pilot study of young healthy people (n=2000) which is not an adequate sample size upon which to base a major public health decision (in addition to which these data have not been peer reviewed). When one studies young healthy people there are few events for even the best vaccine to prevent! Stay tuned for more on the AstraZeneca vaccine and these variants-the data to date are not compelling in terms of any possible lack of efficacy against this strain.
FAQ 2) I’m on a blood thinner, can I be vaccinated for COVID-19? Short answer YES. Here is a more detailed answer from a Canadian agency with expertise on the use of blood thinners, Thrombosis Canada.
FAQ 3) I have a history of allergic reactions, can I be vaccinated for COVID-19? Short answer YES. Out of ~1.8 million vaccinations there have only been 21 reported episodes of anaphylaxis (the most serious type of allergic reaction). Most (70%) of these events occurred within 15 minutes of the vaccine (while the patient is still being monitored, as summarized in a Jan 6th MMWR CDC article). There were also 83 cases of non-anaphylaxis allergic reaction after Pfizer-BioNTech COVID-19 vaccination with symptom onset within the 0–1-day risk window. Most (87%) of these allergic reactions were classified as nonserious.
So while there is not zero risk, the risk of severe allergic reactions to the Pfizer vaccine are low and manageable. Allergy testing is NOT necessary prior to COVID-19 vaccination even in people with history of allergies. It is important note that none of the people who developed anaphylaxis after vaccination died and most did not have a prior history of anaphylaxis (see table below). The incidence of anaphylaxis is lower still with the Moderna vaccine.
The adverse effects of the COVID-19 vaccines clinical trials are similar in vaccinated people vs people (in the clinical trial who got a placebo-saline injection) except for local pain at the vaccine site and increased muscle ache and headache, all of which were short-term (see below). This is a very good safety profile relative to other vaccines.
The CDC does advise against the use of the two mRNA vaccines for a very select group of people with the following allergy histories (click here):
CDC considers a history of the following to be a contraindication to vaccination with both the Pfizer-BioNTech and Moderna COVID-19 vaccines:
- Severe allergic reaction (e.g., anaphylaxis) after a previous dose of an mRNA COVID-19 vaccine or any of its components
- Immediate allergic reaction of any severity to a previous dose of an mRNA COVID-19 vaccine or any of its components (including polyethylene glycol [PEG])*
- Immediate allergic reaction of any severity to polysorbate (due to potential cross-reactive hypersensitivity with the vaccine ingredient PEG)*
FAQ 4) I’m immunosuppressed, should I get vaccinated? This question has a less clear answer. First, be reassured is no virus (dead or alive) in the Pfizer or Moderna vaccines so it is not possible for a person to get infected from the vaccine. However immunosuppressed people were not included in the initial clinical trials. That said, they probably are safe to be vaccinated but this is more a matter of expert opinion. In Canada the National Advisory Committee on Immunization (NACI) currently advises that the COVID-19 vaccine should not be offered to populations excluded from clinical trials “until further evidence is available.” However, they also say (an immunosuppressed person or those with an autoimmune disorder can still be vaccinated if a risk assessment deems that the benefits of vaccine outweigh the potential risks for the individual.” (click here).
The British Society for Immunology recently issued a statement indicating that vaccination is safe in immunosuppressed people (click here), albeit the resulting immune response may be weaker. They remind us that because there is no virus in the vaccine there is absolutely no risk of acquiring COVID-19 from the vaccine.
Our own Dr. Mike Beyak (gastroenterology) nicely summarized evidence from a registry of ~4500 patients who were immunosuppressed for their inflammatory bowel diseases (Crohn’s disease and ulcerative colitis) at this morning’s Zoom Medical Grand Rounds (see below). There was no increased risk of contracting COVID-19 in these 4500 patients. Apart for patients on prednisone, there was also no increased complications from COVID-19 when it occurred. Interestingly, some biologic therapies (antibody treatments for IBD) actually appear to reduce adverse outcomes in IBD patients who contracted COVID-19. This is not surprising since the truly bad outcomes in COVID-19 seem to occur in people who mount a hyper-aggressive immune response.
Overall these data are good news for our many patients with rheumatoid arthritis, asthma and IBD who are on immunosuppressive therapies. However, since these people were not included in the vaccine clinical trials, it is advised they consult the physicians/clinic that is managing their care to inform their vaccine decision.
FAQ 5: How long can I wait after my first dose to get a second vaccine dose? The Ontario science table which deals with COVID-19 (on which our own Dr. Evans participates) has looked at the efficacy of delaying the second vaccine dose to 42 days. It appears a second dose at day 42 is as effective in producing a neutralizing antibody response as when the dose is given at day 21 (the normal interval from dose 1). This more lenient 42-day protocol has been approved by Health Canada.
FAQ 6: Can I get COVID-19 from the vaccines? This answer is simple-NO! None of the approved vaccines in Canada contain the virus itself. They do not contain live virus; they do not contain dead virus. Canada’s approved vaccines (from Pfizer and Moderna) contain only the messenger RNA (genetic code) to allow you cells to make the viral spike protein which then triggers your immune cells to build anti-spike antibodies which protect you. So, while you might get a sore arm or a fever from vaccination this is just your immune system responding as it should; there is no chance of getting COVID-19. Obviously one could contract COVID-19 around the time of vaccination the normal way, before the vaccination’s protection develops (i.e. in the first 2 weeks after vaccination).
3) Ontario’s epidemic is much better controlled since the lockdown with rates of new cases below 1500/day (1265 new cases yesterday and only 901 people in hospital)-but we now have cases with all 3 variant viruses (UK, Brazilian and South African) (click here).
The COVID-19 epidemic is markedly improved in Ontario with new case rates below 1500/day. The rates of active cases/week has declined 23%, deaths 18% and hospitalizations 20% (see below). If it were not for the emergence of mutant virus and the slowness of vaccination delivery we would be out of the woods. However, between these two realities and the existence of local hotspots, continued public health vigilance is required. Ontario’s test positivity rate is 4.4%.
Update: Toronto public health just reported the first case of a COVID-19 infection due to the Brazilian P1 SARS-CoV-2 variant (click here). The highly contagious P.1 variant in Ontario was found in a resident who travelled from Brazil. They are now hospitalized. Ontario now has had cases related to UK, South African and Brazilian mutants. This is a reminder that it is a small world and traveling humans are the virus’ vector of choice!
Rates of new cases and positive tests are half what they were pre lockdown on Dec 26th 2020
4) KFL&A COVID-19 rates remain amongst the lowest in the province (see update from KFL& A Public Health)The total number of cases in KFL&A since the pandemic began has increased 5 since Thursday and is now 677, not counting the prison outbreak. There has only been one death of a KFL&A resident since the pandemic began. There are 15 active cases in the community, up from 11 active cases 1 week ago. We did 2548 in past 4 days 17 positive (0.7%) 3/885 from KFL&A were positive. There are 6 COVID-19 patient hospitalized at KGH, all in ICU. There are 32 active cases in South Eastern Ontario (12 cases in Leeds Lanark and Grenville, 15 in KFL&A and 5 in Hasting Prince Edward county). There are 4 COVID-19 outbreaks, 2 in KFL&A. Regarding local prisons things have improved. There have been no positive tests in the past week.
Rates of new and active cases have plateaued in KFL&A
5) Canada’s COVID-19 epidemic continues to improve: There have been 804,263 total cases to date with 3,203 new cases yesterday and resolution of 89.7% of cases. There are decreases in active cases (-17%) and hospitalizations (-15%) and deaths (-22%) (click here) (click here).
Our second wave of COVID-19 (orange line-top panel below) has been improving for several weeks, with a continuing 20% decline in the weekly rates of new cases (see below). We are now seeing the expected fall in hospitalizations, both for the majority of patients (cared for on Medicine services-gold graph on left below), and the 24% of people in ICU beds (red graph on right below). There have been 20,767 COVID-19 deaths thus far (a cumulative national case mortality rate of ~1.97%). Canada has performed 22.83 million COVID-19 tests with a cumulative test positivity rate of 3.52%.
Decline in active COVID-19 cases, hospitalizations and deaths in Canada (click here).
Rates of infection have plateaued in all Western provinces (BC to Manitoba) as a result of introduction of more aggressive public health measures. Saskatchewan too has now seen a decline in rates and assumed a new lower plateau trajectory. Rates in Ontario and Quebec (home to almost 63% of all Canadians) are experiencing a lockdown-induced decline. Rates of new infection have remained begun to decrease in New Brunswick. Infection rates remain flat in the other Maritime provinces. The outbreaks in the North have been controlled with few new cases in the NWT, Yukon, and Nunavut.
6) The COVID-19 global pandemic: There have been 106,246,361 cases and 2,319,104 deaths since the pandemic began. Active case rates are declining (click here) and positive test rates in the USA have declined to levels last seen in July 2020.
The number of cases globally has increased >6-fold since early August, 2020, when there were 16 million cases. The pandemic hot spots are still the USA, India, Brazil, the United Kingdom and Russia. A positive note is the observed decline in the daily number of active cases (see bottom right orange graph).
Global COVID-19, Feb 8th 2021: The number of active cases world-wide (salmon dots on map) is declining (orange graph on right)
The USA, with 27,008,760 cases and 454,060 deaths, tops the COVID-19 list and accounts for ~25.4% of the global pandemic (up from 21% pre-Christmas). The USA only accounts for ~4% of the world’s population (see below). There are as many cases in America as in India, Brazil, UK and Russia combined! The ONLY solutions to this are adherence to public health measures and rapid mass vaccination.
Improving USA positive test rates (click here): The USA has seen continued reduction in positive test rates for several weeks (now at 7.2%, the lowest since July 2020, click here) (see below). This improvement likely relates to factors other than the vaccine, and will only improve further with America’s relatively effective vaccine rollout program.
Continued improvement in positive test rates in the USA, Feb 8th 2021
The US-Canadian border closure has been extended until at least Feb 21st, 2021 (click here). That said, Canadians can still fly to America (certain rules apply) and as discussed in my note in early December, Canadian citizens can return to Canada from America, with a number of new requirements, including negative COVID-19 tests and quarantine, discussed earlier in this note, point #2).
7) Improvement in COVID-19 in Ontario’s Long Term Care facilities (LTC): Most COVID-19 deaths occur in people who are not only old but who are also frail and live in nursing homes and LTC facilities. As of today, the 3,669 deaths in nursing homes (up 42 deaths since Monday) account for ~57.2% of all deaths. In contrast, LTC residents account for only 5.3% of all cases in Ontario, click here. There are ~ 494 active COVID-19 cases in LTC residents and 686 active cases in LTC staff. These numbers are declining each week which is very encouraging! These statistics (see below) show the impact of the province’s decision to prioritize vaccination of health care workers and residents of Ontario’s LTCs. In KFL&A we will finish the vaccination of LTC residents by mid-February.
Regular reminders
KHSC bed capacity: Bed capacity is adequate with 83 beds available (up 22 beds from Thursday) and good ventilator capacity (see graphic below). Our ventilator supply remains good. Critical care beds are never plentiful but there is better reserve than we have seen in the past month (see below). Medicine remains busy with our doctors caring for people in 174 beds, not including ICU beds on Davies 4 staffed by the Medicine program.
Slight improvement in critical care capacity at KHSC
We are committed to providing care to the 99.9% of patients in SE Ontario who do not have COVID-19. In addition to acute care for heart attacks, strokes and trauma etc., we are continuing to provide elective care. We recognize that the term “elective care” is really a misnomer. Many “elective” patients have chronic pain and disability or suffer from cancer and other serious diseases and will not tolerate delay in care. We continue to encourage 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!
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”: All patients should complete our pre-screening questionnaire before their clinic visit. This will screen out people who are sick and expedite entry to the facility. 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. If a family member is coming in from a high prevalence area they cannot enter KHSC (i.e. they will fail the screening question). There are exceptions made for exceptional circumstances, particularly for palliative or dying patients. Our policy is necessary to prevent importation of infection to the hospital which would impair our ability to care for all patients. 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). 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).
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.
COVID-19 in toddlers and young children: (click here). The situation in Ontario schools remains stable (albeit only 7 regions in low COVID-19 areas are back in session in person). The good news is the reopening in the 7 areas where it was permitted has not resulted in major increases in new cases. Below is the new baseline report for school age children in publicly funded Ontario schools. School boards report every weekday from Monday to Friday. There have been 5174 students with COVID-19 since the pandemic began; 43 new cases in the past 2 weeks (see below).
Here are the parallel data from licensed child care facilities in Ontario-where there have been 1150 children infected since the pandemic began, 163 new cases in the past 2 weeks.
Stay well!