July 27, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
1. Agricultural workers in the Windsor area continue to be infected with COVID-19, related to inadequate housing. Meanwhile, some neighborhoods in Toronto have 25X the prevalence of COVID-19 as others, again related to poverty and overcrowding. This epidemic feeds off what Robert Burns famously called, Man’s inhumanity to man (it applies to women too). Read his dirge below.
Man was made to mourn: A Dirge
Many and sharp the num'rous ills
Inwoven with our frame!
More pointed still we make ourselves
Regret, remorse, and shame!
And man, whose heav'n-erected face
The smiles of love adorn, –
Man's inhumanity to man
Makes countless thousands mourn!
2. A genetic susceptibility to more severe outcomes of COVID-19 is emerging and one risk factor seems to be your blood type.
3. There will be an all staff open forum virtual town hall on Wednesday at 1230
Local COVID-19 Update KFL&A:
There were 2 new COVID-19 case last Friday (see graph below). The running total for the epidemic is now 108 cases in the KFL&A region (see update from KFL&A Public Health). The two new cases were acquired outside our region at a house party. KFL&A has 3 active cases and they are recovering in the community. Our stable local epidemiology is consistent with the ongoing improvement in the epidemic across Canada and in Ontario. There are no inpatients with COVID-19 in KHSC.
SARS-CoV-2 Testing: Over the past 3 days we have performed 1267 SARS-CoV-2 tests. There was only 1 positive test (from the Kawartha area). Our test positivity rate in KFL&A continues to be lower (at 0.4%) than the provincial average (1.9 %).
Ontario’s COVID-19 epidemic: The special case of Windsor and its agricultural industry (click here) Ontario’s prevalence rate is 260.2/100,000, much higher than in KFL&A, at 51.2 cases/100,000 population. Toronto still has a rate >8 times higher (451.1 cases/100,000 population). The region with the highest prevalence of COVID-19 is Windsor (511/100,000), likely because of a poorly regulated agricultural sector and suboptimal housing of farm workers. Over the weekend there were 56 new cases in Windsor and 25 were in agri-farm workers,19 were acquired through community spread, three were in healthcare workers and several more cases remain under investigation (click here).
We will need to properly house people, in communities and on farms, if we want to slow the spread of this virus. Whether it is a nail salon or a farm of migrant workers, we need to treat people properly and provide them with a safe, ventilated work space and living space. COVID-19 outbreaks have an uncanny way of tracking sites in which there is poor treatment of people. Like most infectious diseases, COVID-19 infection rates usually reflect social determinant of health (poverty, overcrowding, etc.), the exception being cruise ships! In the Windsor area 1,035 of 2180 total cases of COVID-19 occurred in workers in the agri-farm sector. The story below illustrates the living conditions these workers experience. We need the provincial government to step in and regulate housing for farm workers. Even the least compassionate human can recognize this environment allows SARS-CoV-2 to spread like wild fire (click here).
The bed of a migrant farm worker in a Double Diamond bunkhouse in Windsor-Essex
(11 other people shared the small space).
Despite this grim news, provincially the epidemic is in decline. There were 137 new cases yesterday (up 0.4% from yesterday). Ontario has had a total of 38,680 total cases and 2763 deaths to date. The 0.6% rate of positive SARS-CoV-2 tests yesterday continues a trend of low positivity rates which we have seen for the past 2 weeks, consistent with the epidemic being controlled.
On the ongoing theme that SARS-CoV-2 is a litmus test for social inequities let’s consider the epidemic in Toronto (click here). Don’t think of Toronto as a single city; rather, think of it as a collection of neighbourhoods with vastly different realities and social/economic and health circumstance. For example, the Beaches has 74 cases of COVID-19/100,000 residents. In contrast, Humber Heights/Westmount has 1829 cases/100,000! There is no single “Toronto”, as seen through a COVID-19 lens.
While things are gradually improving in Toronto (overall), it remains in the yellow zone due to these local hotspots (click here) and graphic below. Toronto remains in Stage 2 of recovery. The best way to stop the epidemic in Toronto is to address housing conditions in its poorest neighbourhoods.
Why do some people get COVID-19 more easily or develop worse disease? In a genetic study form Spain and Italy, a group used a technique called genome wide association study (GWAS) to identify the region of the human genome associated with worse lung outcomes. They studied 1980 patients (click here), see Manhattan plot below. They found two areas in the genome that were associated with severe outcomes from disease (rs11385942 at locus 3p21.31 and rs657152 at locus 9q34.2). What does this mean? Not much yet-but it’s a clue. While they couldn’t identify a specific “severity gene” (GWAS rarely does); however, At locus 3p21.31, the association signal spanned the genes SLC6A20, LZTFL1, CCR9, FYCO1, CXCR6 and XCR1 (i.e. these may be culprits). Perhaps more interesting is that locus 9q34.2 coincided with the ABO blood group locus. They also found a higher risk of bad outcomes in people with blood group A than in other blood groups (and noted O blood type was protective). It may well be that some of us are much more at risk than others, which may help us better target interventions.
The first wave of Canada’s epidemic is resolving (although there is an increase in cases in Alberta, BC and Saskatchewan in the past week) We have had 113,901 cases of COVID-19 in Canada and 8893 deaths (see below). Most cases are resolved. The situation in Canada remains good, with low levels of hospitalization (top left below), low rates of new cases (top right below) and most cases resolved (bar graph bottom left). There are however concerns about focal outbreaks on farms in Ontario and increases in disease incidence in the Western provinces, related to people associating without respect for masking and physical distancing. A reminder: we remain as susceptible to this virus as we were last year!
Canadian aggregate data
No one in Canada can be complacent. Things have been great in Saskatchewan for most of the epidemic; however, clearly there is a rise in the disease now, as people begin to assemble with less caution (see below).
A resurgence of COVID-19 in Saskatchewan
Even the Amazon rainforest is affected by COVID-19. Likely transmitted to Amazonia by tourists, the virus is having devastating effects on indigenous people in these remote areas (click here). 9.1 percent of indigenous people who contract the disease in the Amazon are dying, nearly double the 5.2 percent rate among the general Brazilian population. As this article notes “Indeed, government health-care workers, together with illegal mineral prospectors and other intruders, now figure among the principal vectors of infection into protected indigenous territories.”
In Canada our motto cannot be “Better than Trump’s America”. We must continue to practice physical distancing, handwashing, use masks in indoor spaces and stay home when sick. We also need to be tested when symptomatic. The vast majority of Canadians lack immunity to COVID-19 and wave 2 is a real (and to some extent expected) possibility.
A recent survey of blood donors in BC found <1% of people had antibodies to COVID-19 (meaning they remain as susceptible to the virus as they were before the epidemic reached our shores) (click here). Indeed the case incidence rate has begun to increase again in BC.
The ~78,000 residents of Ontario’s LTC facilities account for less than 0.5% of the population but they still account for ~67% of all deaths from COVID-19! There have been 1844 deaths to date. There were 3 deaths over the past week in Ontario’s LTCs. Canada had the highest rates of mortality in LTCs of any surveyed country (click here)! This is sad indictment of Canada’s LTC facilities and attests to a lack of government oversight and lack of a comprehensive plan for senior care.
Testing for SARS-CoV-2 (click here): We have tested 10.76% of all Canadians (4,111,820 people). The rate of test positivity is declining and nationally is 2.77% (vs 1.89% in Ontario). Ontario SARS-CoV-2 testing continues at a rate that exceeds the national average, with 14.12% of Ontarians having been tested (see below). A very promising sign is that with more testing we are finding a lower rate of positive test results. More COVID-19 testing does not “produce more cases” (and it will also not increase the rate of finding cases unless they exist, undetected in the population).
COVID-19 testing in Ontario July 27th 2020
In contrast with Canada’s 2.77% rate of positive test, the USA has an average rate of positive COVID-19 tests of 8.2%. However, Texas, Florida and Arizona are in trouble, with rates of 12.9, 19.2 and 22.7% (click here)! Florida and California are now at the same case burden that New York has experienced.
The COVID-19 pandemic has grown by 4.8 million cases in 3 weeks! There are now 16,296,635 cases globally and 649,662 deaths. On July 6th there were “only” 11.5 million cases and now, 3 weeks later, there are 4.8 million more cases. The pandemic hot spots are in the Americas (Brazil, Mexico, Peru, Chile and USA), Russia, and India (click here). The USA alone accounts for 26% of the global pandemic. The data sheet below shows countries where there are more than 100,000 cases to date (click here). It also shows the active cases globally. Our poor little planet looks like it has measles!
Where to get a COVID-19 test?
- A) The public: Leon’s Centre testing facility is open for COVID-19 testing of community members (click here for details of hours). The wait time at Leon Centre is short (10 minutes).
- B) KHSC staff: Should KHSC staff develop symptoms consistent with COVID-19, please do not come to work! Instead, contact occupational health and safety and they will tell you how to proceed (ext 4389 at KGH site, or emailCOVIDrtwadjudication@kingstonhsc.ca). You will likely be tested at the Hotel Dieu testing centre. Results are usually available next day.
KHSC capacity: We continue our surgical ramp-up and resume our ambulatory care ramp up to provide better care for the 99.9% (click here for more on this). KHSC has capacity for our elective procedure ramp up; but things are busier, with the hospital inpatient census now exceeding 400 patients. One risk to our capacity is the resurgence in the numbers of Alternate Level of Care (ALC) inpatient people. We had reached a low of 20 ALC people and are now back up to a census of 40 ALC people . These are people waiting LTC and retirement home placement and by definition should not be in hospital. They are “stranded” here as they await a return to home or an LTC. This puts our capacity to provide care for the 99.9% in jeopardy.
Universal Masking Policy:
How many masks are we using? We are using 5300 masks/day at KHSC as part of our universal masking process. We have ordered 1 million masks.
How many people can get on a hospital elevator now that we are universally masked? Because dwell time in elevators is brief, we are allowing up to 6 masked people on hospital elevators.
All people entering the hospital are required to wear a mask (unless an exemption has been prospectively obtained). MASKS WILL BE PROVIDED AT ALL KHSC ENTRY POINTS. You will be allowed to wear a cloth mask when entering the building (this includes both staff and visitors).
- a) Fabric masks cannot have an exhalation valve.
- b) Fabric masks cannot be used in patient care.
If you use a hospital provided medical mask:
- a) they should be reused for a week, storing it in a paper bag when not in use (bag provided). These are not single use masks.
- b) these masks can be used in patient care as well, with the sole exception of caring for a patient on droplet precautions, such as a patient with COVID-19. In these cases you will need to get a different mask which is available at the nursing station.
Occupational health will be reviewing requests for exemption. When there is an exemption, it will usually mean that a face shield will be worn as an alternative (i.e. some form of facial PPE will still be required). An important reminder however; face shields are not as effective as masks and personal exemptions will likely be rare.