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January 21, 2021 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

Headlines

All patients admitted to KHSC will undergo Covid-19 testing

1) School’s back in session for in person learning in KFL&A, Hasting Prince Edward County and Leeds, Grenville and Lanark District Health Unit effective Monday, Jan. 25, 2021.

(click here)!

2) Vaccine Myth-busters and FAQs: Myth busting to reassure people who are immunosuppressed, have allergies or are on blood thinners that vaccination is safe plus a link to Canada’s COVID-19 vaccine tracker and explanation why there are temporary vaccine shortages (click here).

3) KHSC receives patients from Toronto-no new transfers today 

4) Provincial lockdown order for Ontario: It is working! (click here)

5) Ontario’s epidemic is better controlled with a rate of test positivity of 4.9%, 1533 hospitalized patients (388 in ICU) and 2655 new cases/day (click here).

6) COVID-19 rates continue to improve in KFL&A (see update from KFL& A Public Health)

7) Canada’s COVID-19 epidemic: 728,127 total cases to date, 66,601 active cases (down from 73,635 on Monday)and 18,508 deaths (a cumulative national case mortality rate of ~1.9%). To date 682,141 people have been at least partially vaccinated (click here)

8) The COVID-19 global pandemic: Global mortality is 2,078,315 million people with over 97 million cases in the pandemic to date (25% from the USA which has only 4% of the world’s population) (click here):

9) A big thank you to our KHSC Incident Command committee.

1) School’s back in session for in person learning in KFL&A, Hasting Prince Edward County and Leeds, Grenville and Lanark District Health Unit effective Monday, Jan. 25, 2021.

(click here)! In news that will make most parents fell like Capt. Steven Hiller (Will Smith) in the movie Independence Day…the kids are headed back to school!. Independence Day the movie addressed the question whether humankind was alone in the universe; school reopening addresses the question whether parents will ever get to be alone in their homes!

movie poster for independence day spaceship shining light on NY city

Here’s the good news, made possible in 7 Ontario counties because of their favorable COVID-19 epidemiology. This success is not an accident; rather it reflects good public health leadership and effective participation of the public.: “On the advice from the Chief Medical Officer of Health, the government is allowing seven public health units and over 100,000 students to return to class on Monday,” reports an article in the Kingstonist. “Getting students back into class is our top priority,” the release continued. “According to Ontario’s Chief Medical Officer of Health and leading medical and scientific experts, including the Hospital for Sick Children, Ontario schools are safe places for learning. To ensure schools remain safe, the government is introducing additional measures including province-wide targeted asymptomatic testing, enhanced screening, mandatory masking for students in grade 1-3 and outdoors where physical distancing cannot be maintained.”

2) Vaccine Myth-busters and FAQs: Myth busting to reassure people who are immunosuppressed, have allergies or are on blood thinners that vaccination is safe plus a link to Canada’s COVID-19 vaccine tracker and explanation why there are temporary vaccine shortages (click here).

FAQ 1) I’m on a blood thinner, can I be vaccinated for COVID-19? Short answer YES. Moreover, you don’t need to consult a cardiologist or other specialist to get the green light. Here is a more detailed answer from an Canadian agency with expertise on the use of blood thinners, Thrombosis CanadaThanks to Dr. Mike O’Reilley from Cardiology for bringing this to my attention.

logo for Thrombosis Canadamemo providing guidance for people on warfarin and getting covid-19 vaccine

FAQ 2) 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 summarised 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.

article headline re allergic reactions after getting covid vaccine

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).

table giving cdc advice on the issue of allergies and vaccines

CDC advice on the issue of allergies and vaccines (blue table below)

memo from CDC re allergic reactions to covid 19 vaccine

FAQ 3) 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).

Dr. Fauci from the NIH is the USA is quoted as saying that, despite being excluded from clinical trials, this population should get vaccinated. “I think we should recommend that they get vaccinated,” he said. “I mean, it is clear that, if you are on immunosuppressive agents, history tells us that you’re not going to have as robust a response as if you had an intact immune system that was not being compromised. But some degree of immunity is better than no degree of immunity.” (click here).

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).

ppt slides screen from Medical Grand Rounds

presenter at podium with presentation on large screen behind him

 

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. This is 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.

Vaccination roll-out update: The roll out is moving along, dealing with logistical challenges and supply chain problems (notably Pfizer stopping vaccine supply for 1 week  and then reducing supply for a month as it retools a factory in Belgium). To date we have not had to deal much with people declining vaccines; rather we are dealing with a pent up demand for vaccines that far exceeds supply. Mr Trudeau has indicated all Canadians who wish to be vaccinated will be vaccinated by September (click here). 

In total, 917640 doses of COVID-19 vaccines (including both Moderna and Pfizer-BioNTech) have been delivered for administration and 75.9% of delivered doses have been administered. The Pfizer-BioNTech and Moderna vaccines require two doses, a number of weeks apart. As of today, the vaccine tracker reports that 651,168 Canadians have received at least one dose of an approved COVID-19 vaccine. At least 45,074 Canadians are fully vaccinated, having received both required doses.

map of Canada with number of doses of vaccine given listed for each province

3) KHSC receives patients in transfer from Toronto hospitals (as we assist in decompressing their ICU and Medicine beds)

There has been a decision by the province to distribute Toronto cases to less congested regions, since their ICU capacity has been overwhelmed. Hopefully with a new MacKenzie hospital opening in Vaughan (click here) and flattening of the provincial COVID-19 curve transfers will not occur in large numbers. There were no transfers to KHSC today. The physician leaders at KHSC are working closely with the hospital to ensure we retain capacity to care for the 500,000 people in Southeastern Ontario who get care for their critical illnesses at KHSC.

4) Provincial lockdown order for Ontario: It is working (click hereThe new Ontario lockdown rules (see last note), intensified a lockdown which began Dec 26th is working! While lockdowns work to slow viral spread, they do bring social isolation, impair health care access for people with non-COVID-19 diseases, exacerbate mental health challenges and create adverse economic consequences. There is early evidence this lock-down pain is yielding some gain. The graph below shows a modest decline in new cases in Ontario, coincident with the post-Christmas lockdown (see orange line in top panel below).

graph showing new data effects of lockdown in Ontario

Effects of lockdown: Active cases have plateaued (orange line at top) and hospitalizations have stopped rising (gold graph above) Jan 21st 2021 (click here).

Thus far our amazing KHSC vaccine team has delivered 2128 vaccines and operationalized a new mobile pilot program that gets the vaccine out to our long term care facilities. All vaccines thus far have been given to LTC staff and residents. We have now administering a second shipment of Pfizer vaccine that we will be administering in the coming week. Because of the Pfizer decision to retool its Belgium factory (with the goal of enhancing vaccine capacity in a month or so) (click here), there will be Canada-wide delays in vaccine supply. On a more positive note, there will be Moderna vaccine arriving in south eastern Ontario soon. This vaccine will also initially be given to LTC residents per order of the province. We do not know yet when we will be vaccinating our faculty and staff; however, there has been strong advocacy for ensuring that our frontline workers and faculty get vaccinated as soon as possible by our CEO, Dr David Pichora. 

An interesting update on the time interval between vaccine dose 1 and dose 2: Ontario’s 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.

needle and syringe drawing vaccine from a bottle

Important factors that guide the KHSC vaccine team:

  1. Prioritization of populations for vaccination as dictated by the province
  2. The clinic will run 7 days/week. 
  3. No doses will be wasted. Any reserve vaccine capacity will be used to vaccinate heath care workers on an on call basis.
  4. KHSC is a regional centre for vaccine distribution so equitable access will be ensured for LTC workers and health care workers at other regional hospitals and clinics.

5) Ontario’s epidemic is better controlled with a rate of test positivity of 4.9%, 1533 hospitalized patients (388 in ICU) and 2655 new cases/day (click here).Ontario has had 247,564 COVID-19 cases, 2632 new cases since yesterday (a continued decline from many days over 3000 new cases). Our provincial positive COVID-19 test rate continue to decline from 9.7% 2 weeks ago to 4.9% today. This is the lowest test positive rate in Ontario since December. Ontario’s provincial COVID-19 rate is 1665.5/100,000 population, 5-times higher than in KFL&A (296.6 cases/100,000 population).

table summarizing Ontarios pandemic at a glance

Ontario’s pandemic at a glance: Jan 21st 2021 (click here)

COVID-19’s large second wave in Ontario is improving with 26,063 active case, down almost 3000 from Monday. Hospitalizations, though numerous (1598 people in hospital today), have also plateaued (see below). The good news is that active case numbers have begun to plateau as a result of the lockdown (pink graph at top).

two graphs on top of each other giving different data

Most patients with COVID-19 are cared for on Medicine wards (gold above) and the balance are in ICU (black line in graph above) (click here). This ~4/1 ratio of ward to ICU admissions has been fairly constant throughout the pandemic. 

Peel (on Toronto’s western border) remains the hot spot in Ontario with 3084.9 cases/100,000 population (click here)Toronto’s prevalence remains high at (2469.6 cases/100,000 population, >3X the rate 2 months ago (711 cases/100,000) and ~8 times higher than Kingston, 296.6 cases/100,000). Windsor (2680.6 cases/100,000 population) and Ottawa (1199.7 cases/100,000 population) remain hotspots. Eastern Ontario, around Cornwall, continues to rise rapidly (1066.5 cases/100,000). 

photo from the water looking at Toronto's waterfront with CN tower and Roger's centre

Toronto remains a collection of neighbourhoods with vastly different COVID-19 realities due to differences in social/economic, racial and health circumstances. The burden of COVID-19 disproportionately affects black, middle eastern and southeast Asian populations (relative to Whites) Although COVID-19 is increasing in the city as a whole, case load is widely variable amongst Toronto neighbourhoods. Since the pandemic began, the Thistletown-Beaumond neighbourhood has had 7,191 cases/100,000 residents, ~ 10X the burden of COVID-19 in the Runnymeade-Bloor West Village neighbourhood (655 cases of COVID-19/100,000 residents). When one examines recent cases (i.e. those diagnosed in the past month), case prevalence is still high-ranging from 83 cases/100,000 residents in Mount Pleasant East to 1364 cases/100,000 residents, in Humber Summit (click here).

We should avoid elective travel to and from these hot spots from lower prevalence areas, like Kingston.

6) COVID-19 rates continue to improve in KFL&A (see update from KFL& A Public Health)

The total number of cases in KFL&A since the pandemic began is now 645, not counting the prison outbreak. There has only been one death of a KFL&A resident since the pandemic began. There have been 6 new cases since my Monday note. On a positive note there are fewer active cases in the community (12) down markedly from the 52 active cases 2 weeks agoThere are 5 COVID-19 patient hospitalized at KGH (most from Toronto). There are only 60 active cases in SE Ontario, which is also good news (down from 71 on Monday). There are 5 outbreaks in the region (down from 16 in late 2020). Kudos to Dr. Kieran Moore and his team at Public Health for helping keep us in good health!

Graph showing plateau of positive cases in KFL&A

New case rates have plateaued in KFL&A Jan 21st 2021

Map of Ontario with purple dots

This slide, courtesy of Dr Gerald Evans, shows Kingston in the green with a very low number of weekly COVID-19 cases 6/100,000, relative to other areas in southern Ontario.

Testing: We have done 2788 tests for SARS-CoV-2 in the past 3 days and 25 were positive (a rate of 0.9%). There were no new cases in Kingston itself. There remains a need for genomic surveillance to detect viral mutations. The mutations to date all appear to be susceptible to vaccine protection. However the N501.V2 mutation (initially found in the UK) seems to be more infectious, especially amongst young children (stay tuned). It is highly likely to be vaccine sensitive (click here). The E484K variant found in South Africa, Brazil and Japan is still being studied to ensure that it does not have immune evasion capacity (click here).

Bottom line: The vaccine will ultimately 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. This is the final leg of a marathon and the next 3-4 months will challenge us all to remain patient and follow policies that we acknowledge have harsh financial and social consequences. However, there is light at the end of the tunnel in the form of the vaccines.

black and white tunnel with railroad tracks

7) Canada’s COVID-19 epidemic: 728,127 total cases to date, 66,601 active cases (down from 73,635 on Monday)and 18,508 deaths (a cumulative national case mortality rate of ~1.9%). To date 682,141 people have been at least partially vaccinated (click here) Our second wave of COVID-19 (orange line) has reached a plateau and is beginning to decline (see orange line below showing active cases). It is noteworthy that Ontario has caught up to Quebec in total case numbers (not adjusted for Ontario’s larger population).

various types of graphs showing Canada's Covid-19 data

COVID-19 in Canada: Wave 2 has plateaued-Jan 21st, 2021 

87.9% of all cases have already recovered. There has been a 1.9% national mortality rate amongst people diagnosed with COVID-19 (see below). 

Rates of infection are high in all Western provinces (BC to Manitoba) but with introduction of more aggressive public health measures rates in these provinces have plateaued. Manitoba remains a great example of the benefits of a lockdown as a means to control active case spread pre-vaccine. Saskatchewan has seen a rebound in rates (I’m not sure why). Rates in Ontario and Quebec (home to almost 63% of all Canadians) appear to have hit a plateau and have begun to decline. Rates of new infection have remained high in New Brunswick (see below) but 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.

8) The COVID-19 global pandemic: Global mortality is 2,078,315 million people with over 97 million cases in the pandemic to date (25.2% from the USA which has only 4% of the world’s population) (click here):

There has been a total of 2,034,705 million deaths and 97 million cases since the pandemic began.The number of cases has increased ~6-fold since early August, 2020, when there were 16 million cases. The pandemic hot spots are in the USA, India, Brazil, and Russia, with the UK, France and Turkey in hot pursuit! (click here). A positive note is an apparent plateauing of active cases (see bottom right orange graph below)

World map  with pink dots and ranking lists of countries with high covid numbers

Global COVID-19: New cases may have peaked (bottom right): Jan 21st 2021

The USA with 24,446,837 cases and 406,384 deaths tops the COVID-19 list and accounts for ~25.2% 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 and Russia combined! The COVID-19 active case map(above) shows the high incidence of active infections in the US and South America, as well as in Europe (the bigger the salmon-colored dot the higher the active cases/100,000 population). The ONLY solutions to this are adherence to public health measures and rapid, mass vaccination.

Improving USA positive test rates and extension of border closure (click here): The USA has seen a modest improvement in positive test rate of 9.8% (click here) (see below). California has a positive test rate has also decreased to 9.7% whilst South Dakota remains at a staggering 30.9% rate of test positivity today. For snowbirds: rates in Florida remain high (10.7% today)-see below. 

graph showing improvement in positive test rates in US

Improvement in positive test rates in the USA

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 requirements, including quarantine) (click here).

border bridge with US and Canadian flag and title that Canada-US land border closure extended

Regular reminders

KHSC bed capacityBed capacity has reduced to 71 beds (versus a week ago when it was 110 beds) (see graphic below). Our ventilator supply remains good; however, critical care beds are in short supply (below right). We are committed to providing care to the 99% of patients 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 and 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! 

graph for KHSC bed availability

bar graph
 

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.

index finger scrolling on an iPhone and screenshot of pre-screening app for KHSC

KHSC visitor policy: 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 and this family presence policy will be updated by the end of the week (to make it clear who grants final decisions on exceptions that allow access). 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).

animated photo of female receiving nasal covid swab and how far it goes into nasal cavitythree young boys dressed as doctors with stethoscopes and arms folded

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): 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 LTC. As of today, the 3256 deaths in nursing homes (up 106 deaths since Monday) account for ~58% of all deaths in Ontario, click here. There are also ~ 1441 active cases in LTC residents and 1185 of active cases in LTC staff! In the last month the rate of death amongst LTC residents has continued to increase daily and is now >100/week! Outbreaks in nursing homes usually imported by a person coming in from 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). It is because of these grim statistics (see below) that the province has prioritized vaccination of health care workers and residents of Ontario’s LTCs. 

table summarizing current covid data for LTC

COVID-19 in toddlers and young children: (click here). No updates since Dec 21st. Updates will resume soon since in person schooling begins next week.

sign with a crown on top stating Thank you for being such a great team

9) A big thank you to our incident command committee who are dedicated and passionate leaders and who are primarily responsible for our COVID-19 response. Although you might not see our Incident Command leaders on the wards, they have been working tirelessly and effectively throughout the pandemic to keep KHSC and the people of south eastern Ontario safe. Whether it is ensuring we have access to best in province lab testing for COVID-19, rapid response testing in the community, or an exemplary vaccine administration program, we have a lot to be thankful for. The incident command committee includes:

  • Troy Jones (COO)
  • Theresa MacBeth
  • Anne Rutherford
  • Dr. Gerald Evans & Heather Candon (Team IPAC)
  • Rocky Prosser
  • Dr. Mike Fitzpatrick (Chief of Staff)
  • Brenda Carter
  • Elizabeth Bardon
  • Sandra Carlton
  • Amit Bansal (CFO) and 
  • Paul McAuley (3SO-responsible for securing all our PPE supplies). KUDOS!

An additional thanks to Valérie Gamache-O'Leary and her information technology team who launched our REACTS virtual visit platform flawlessly at the beginning of this pandemic. Additional thanks to Lori Van Manenand her tireless vaccine crew, including amazing pharmacists! Finally a shout out to Dr. Dan Howes and our ICU colleagues (nurses, doc, staff) who stepped up to care for the recent influx of COVID-19 patients-well done!

Kingston Health Sciences Centre Logo

Stay well!

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