June 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 June 2020

COVID-19 Update: There are no new cases of COVID-19 in the Frontenac Lennox and Addington (KFL&A) region (see update from KFL&A Public Health). There are no cases in KHSC The running total for the epidemic remains at 63 COVID-19 cases in the KFL&A region. There were 422 tests done and none were positive tests in the lab today. The positive test rate in KFL&A remains at 0.5% (vs 3.8% in Ontario). Our PPE supply is stable with 3 weeks reserve, at the current level of activity.

Care of the 99%: Rational public health policy must consider all-cause mortality, not just the death from COVID-19. Most people are not dying of COVID-19; although it is causing a huge increase in mortality, relative to the levels seen last year. This differential death rate is called “excess mortality”. I previously reviewed an article in the Economist that showed, in addition to excess mortality from COVID-19, countries were experiencing additional mortality excess, likely attributable to delayed care of the diseases like heart disease, cancer etc (click here). While we continue to deal with the pandemic, we urgently need to address non-COVID-19 disease management.

A June 1st New York Times article by Denise Lu (click here) offers another reminder that while people shelter at home and defer elective care, adverse outcomes, including death, are resulting from common and treatable/preventable causes, such as heart attack, stroke, diabetes, and cancer. In New York and New Jersey, 60% of the excess mortality (defined as more deaths this year than last year) is due to COVID-19; however the other 40% reflects non-COVID-19 disease (see graph below).

graph showing deaths due to COVID-19 vs no COVID-19 deaths

In my own area of expertise, heart disease, the numbers are very concerning. In New York state there has been a 3-fold increase in deaths from heart disease (see graph below). For every non-COVID-19 death, one can reasonably assume many more people suffered the adverse consequences of delayed care like a completed stroke, new heart failure or a myocardial infarction., These nonfatal adverse events may do them irreversible harm.

Graph showing deaths due to heart disease

It’s not just people with heart disease who suffer from deferred care. These two states also have experienced 4700 excess non-COVID-19 deaths, from neurological conditions like Parkinsonism and Alzheimer’s disease, between mid March and May (see below).

While some believe these non-COVID-19 deaths are actually misdiagnosed COVID-19 deaths, I do not agree. Heart disease and cancer were the leading causes of death pre pandemic and it would be illogical to believe that the massive reduction in care that people have experienced would not be harmful.

In a recent article in the NEJM (click here) Gogia et al document the magnitude of the deferred care crisis in New York City. They found an 88% drop in non–Covid-19 ICU volume from February 15 to April 15, 2020. Where do these critically ill patients go? What happens to them? Sadly, they likely are reflected in the excess mortality figures as discussed above.

graph showing patients in ICU due to COVID-19 vs non COVID-19 patients admitted to ICU

What happens to the patients in gold? (the non-COVID-19 patients who are no longer being admitted to ICU)

They also found a decline in admission of heart attacks, stroke and cardiac arrest! These are not conditions that permit deferred care. The implications of this fall in admission is that many of these “missing” people would have died or suffered adverse outcomes. This is happening in Kingston and in Ontario in general.

graph showing other circulatory system deaths

The article notes that even as COVID-19 admissions decline in NYC cardiac the other patients are slow to return. Fear of the contagion likely drives system avoidance. One can also wonder how many have lost their employment and with it health insurance, which makes hospital care unaffordable. In any case, these data remind us that ethically we must provide equitable access to care for non-COVID-19 and COVID-19 patients!

Ontario Health has commissioned a committee to provide guidance on expanding ambulatory care; however, this process is slow. In the meantime our physicians continue to see patients with nondeferrable care in our clinics in person and our use of video visits, or other e-health tools, has dramatically increased. The Department of Medicine is doing ~300 video visits/month and this is increasing, with most members signed up on the REACTS platform. That said, many of the most critical forms of patient-doctor interaction must occur in person. Medicine doctors are here to deal with these needs! We are reminding patients that our hospitals and clinics are safe places to receive care (in part because everyone, including staff is screened prior to entry, and in part because the local incidence of COVID-19 remains low). Ontario Health must develop a greater sense of urgency in rolling out its ambulatory care ramp up policy. People should not delay accessing care that they, or their doctor, deem to be urgent. If they are sick they can safely be seen in Emergency rooms, family medicine doctors’ offices and our clinics and in patient wards. One issue that remains problematic for increasing clinic visits is that we can only screen 800 patients per day at Hotel Dieu (down from our normal capacity of 1700 visits/day). We also have challenges with the physical plant that limit the number of patients who can be in a waiting room. The ramp up of clinics remains a work in progress.

The ramp up in elective procedures: KHSC has begun to ramp up surgery (increasing to running 9 operating rooms at KGH and 5 operating rooms at HDH) and has increased endoscopy and cardiac procedural volumes. Patients are being required to self-isolate for 14 days prior to elective surgery-so planning and clear communication with the patient’s undergoing elective procedures is required.

Screening for out of province travel: Our screening test questions have changed and all entering the facility are asked if they have traveled out of province. This new question is provoking some anxiety. The reason for adding the question, at the request of the province, was to identify people from COVID-19 hot spots, such as Montreal (see yesterday’s note). The concern is that returning from high incidence places risks importing disease into low prevalence regions, such as KFL&A. For example, Montreal has 42-times the prevalence of COVID-19 as does KFL&A. The rational concern behind the question is that travel to Montreal could import COVID-19 to KHSC. The irrational part of the policy is that, next to Montreal and Laval, the next hottest spot for COVID-19 in Canada is Toronto (and we do not ask staff if they have visited Toronto)! Like many things in the pandemic, there are political factors at play.

If a health care worker answers “yes” to out of province travel during screening their risk of being infected is assessed by occupational health and their subsequent management is determined accordingly. If they traveled to low risk areas they will likely be allowed to return to work under conditions referred to as Work isolation. In such cases, the healthcare workers must wear a mask, monitor their temperature twice/day and self-isolate immediately if symptoms develop. This work isolation would last for 14 days, even if a SARS-CoV-2 test is negative. If a staff member has questions about this they should contact Occupational Health (ext 4389 at KGH site, or email COVIDrtwadjudication@kingstonhsc.ca).

These policies are changing rapidly. I would strongly advocate for health care workers to avoid elective travel outside the province and, if they travel, return early enough that they can be evaluated/tested prior to returning to work. This is inconvenient; but there is not much about the pandemic that is convenient.

Will Toronto be next on the no travel list? Hard to say, but again, it would be prudent to avoid elective travel to Toronto until their COVID-19 incidence begins to decline. With a new academic year 140 medical residents and fellows are coming to town. My advice to them is to get to Kingston as early as possible, ideally 2 weeks in advance, to ensure they are not required to self-quarantine for 2 weeks.

COVID-19 screening of asymptomatic health care workers (policy in evolution). Currently testing of asymptomatic health care workers is voluntary and staff will be referred to the Memorial centre if they wish to be tested when they are asymptomatic. This testing is to be done on personal time, rather than during working hours.

Universal masking policy (policy in evolution): The Ontario government has suggested universal masking should occur in hospitals. However, this is currently just a recommendation. Such a recommendation may make sense in Toronto hospitals but is unlikely to be needed (at present) in a low incidence region like Kingston. Stay tuned for more on this!

How’s the epidemic going? To date there have been 93,043 cases of COVID-19 and 7495 deaths in Canada (see below). In Ontario, the COVID-19 curve has flattened (see graph below). However, the incidence in Toronto continues to rise and recently a single testing station failed to initiate contract tracing in over 700 people who tested positive. This is a reminder that human error is a great accelerant to the spread of disease.

Flattening of the curve continues in Ontario-but it is not collapsing to zero yet!

However, the disease remains most prevalent in Quebec (below left), with 51,884 cases and 4794 deaths. Quebec accounts for 56% of the cases and 64% of all deaths from COVID-19 in all of Canada. Montréal alone accounts for ~28% of all cases in Canada to date (25,788 cases and 2982 deaths). So this is not the time to be visiting Montréal or Laval for tourist purposes (see below)!

Contrast this to Ontario. Kingston remains in a bubble with a low incidence of COVID-19 (29.1 cases/100,000 population), positioning us to carefully reopen the city and ramp up activity at KHSC and Queen’s University (read the blog if you’re interested in hearing more re: Queen’s). In Ontario as a whole cases are up 1.6% from yesterday to a total of 28,709. Toronto has a rate 11 times higher (338.6 cases/100,000 population) and this rate continues to increase daily (see below).

map of Ontario showing areas with COVID-19

COVID-19 continues to disproportionately affect the elderly (click here). Note that very few people under 40 years of age have been hospitalized in Ontario and children remain relatively free form serious infection.

chart of hospitalized patients due to COVID-19 by sex

Residents of long term care facilities (LTC) (see today’s data below) continue to bear the brunt of the epidemic. The ~78,000 residents of Ontario’s LTC facilities account for less than 0.5% of the population but they account for ~72% of all deaths from COVID-19! There were 9 deaths since yesterday in Ontario LTCs.

Testing for SARS-CoV-2 (click here): We have tested 4.9 % of all Canadians (1,804,383 people) and are at approximately the same rate of testing in Ontario (5.29%-see below).

graph showing COVID-19 tests vs positives

To see where Canada stands amongst nations in the COVID-19 pandemic, click here. The global case total is 6,445,457 and the number of death is up to 382,451. Here is a list of the most affected countries (USA, Brazil, Russia and UK are the top 4). America remains in a league of its own (sadly). It is hard to imagine this will improve with public demonstrations leading to close contact of large numbers of people and a presidential leadership that ignores the need for physical distancing.

ranking of countries/regions with highest COVID-19 deaths

A revised reminder for people in the community (last updated May 27^th)

1) People in the community can self-refer for assessment and possible testing. We are now on testing people for much broader indications (we are no longer requiring fever or travel as preconditions for testing). We are testing people who have only 1 COVID-19-type symptom or who are concerned they have been exposed to the disease. KFL&A has also suggested that health care workers should be routinely and repeatedly surveyed by nasal swabs (discussed above). You can seek out testing at Memorial Centre in Kingston, (see instructions below). Here is a link to the self-assessment tool used to see if you should be tested (although I suspect it will be updated soon): click here.

The Community COVID-19 Assessment Centre is located at:
Kingston Memorial Centre (please use the well-marked main entrance)
303 York Street, Kingston, Ontario
Monday to Friday: 10:00 a.m. - 6:00 p.m.
Saturday and Sunday: 9:00 a.m. - 12:30 p.m.

The fierce urgency of now: This is an excerpt of Dr. Martin Luther King Jr.’s speech in 1963 at the Lincoln Memorial…sadly it resonates today. I offer it as a context to the intensity of today’s protests in America and around the world demanding an end to anti-black racism. The older the injustice the more intense the struggle to set it right. Click here to get the audio of King speaking.

“Five score years ago, a great American, in whose symbolic shadow we stand today, signed the Emancipation Proclamation. This momentous decree came as a great beacon light of hope to millions of Negro slaves who had been seared in the flames of withering injustice. It came as a joyous daybreak to end the long night of their captivity.

But one hundred years later, the Negro still is not free. One hundred years later, the life of the Negro is still sadly crippled by the manacles of segregation and the chains of discrimination. One hundred years later, the Negro lives on a lonely island of poverty in the midst of a vast ocean of material prosperity. One hundred years later, the Negro is still languished in the corners of American society and finds himself an exile in his own land. And so we've come here today to dramatize a shameful condition.

In a sense we've come to our nation's capital to cash a check. When the architects of our republic wrote the magnificent words of the Constitution and the Declaration of Independence, they were signing a promissory note to which every American was to fall heir. This note was a promise that all men, yes, black men as well as white men, would be guaranteed the "unalienable Rights" of "Life, Liberty and the pursuit of Happiness." It is obvious today that America has defaulted on this promissory note, insofar as her citizens of color are concerned. Instead of honoring this sacred obligation, America has given the Negro people a bad check, a check which has come back marked "insufficient funds."

But we refuse to believe that the bank of justice is bankrupt. We refuse to believe that there are insufficient funds in the great vaults of opportunity of this nation. And so, we've come to cash this check, a check that will give us upon demand the riches of freedom and the security of justice.”

photo of Martin Luther King I have a Dream speech

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

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