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KFL&A&A mandating mask wearing

June 30, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

Local COVID-19 Update KFL&A: 

As everyone likely knows this week has been the week where the Kingston COVID-19 bubble burst because of a local outbreak. This outbreak was initially centered on two local nail salons. These outbreaks, though unfortunate, do not indicate a reversal of the gradual improvement in the epidemic we are seeing across Canada and in Ontario. They are not a cause for panic, although they have triggered a change in public policy, requiring public masking in indoor spaces (at Queen’s University and in all places of business in our region). 

The running total for the epidemic is now 93 cases in the KFL&A region (see update from KFL&A Public Health). This reflects 30 new cases related to contact with Binh’s nail salon and Kingdom Nails & Spa. Both of these businesses have been closed and more recently Kim’s L.A. Nails has been closed (although I’m unclear of details at the time of writing) (click here). An interesting fact is that there are ~70 nail salons in our region, and some significant sharing of workers amongst salons. Here is a reminder of what to do if you visited one of these nail salons.

Instructions of what to do if you've visited this nail salon

There are no COVID-19 cases in hospital. All cases are recovering from COVID-19 in the community. 

We have now seen infection transmitted from “first circle contacts” (i.e. people who were actually clients of the nail salons, n=17) to secondary contacts (i.e. people in contact with people who attended the nail salon but who did not attend the salon themselves, n=12). This is a reminder that this virus is highly contagious. It is however also noteworthy (and fortunate) that all these patients are recovering at home reflecting that the severity of their infection did not require hospitalization.

KHSC has good capacity to deal with a potential COVID-19 surge. Our COVID-19 ward is Connell 3. This ward has 35 beds and many single rooms. Drs. Chris Smith and Dr. Gerald Evans have worked with IPAC and KHSC to ensure that we have a hot zone on this ward (for patients with confirmed COVID-19 when/if they arrive) which is separated from a warm zone (for people being tested for COVID-19 but not confirmed to be positive). There is also a physically separated cool zone, which will have separate staff. This cool zone is for people not infected or suspected of COVID-19 infection. However, I want to reinforce there are no patients admitted to KGH with COVID-19.

Quarantine update: Currently there are 45 KHSC staff on quarantine but to date there are no new positive cases in this group, beyond the one reported ~10 days ago. Davies 5 remains in quarantine until Friday, though all tests of patient and staff to date are negative.

Testing is now being performed at the Leon’s Centre (click here for details). We have done ~1988 tests over the weekend, with 7 positive tests, 3 from KFL&A and 4 from the Haliburton-Kawartha area. Congrats to Cindy Bolton, Ashley Hendry and team who arranged a pop up testing clinic in the St. Lawrence College parking lot as a bridge to opening the Leon Centre (now open). There will be another pop up clinic at St. Lawrence College on July 1st.

This is the week of the cloth mask. Masks are now required for access to public spaces in Kingston, including Queen’s University, but are they effective? First let me say-please follow public health policy. What follows is my own opinion and assessment of the literature (#Drscience).

picture of lady sewing face masks

What are the facts about the efficacy of cloth masks? Epidemiologic data suggests that countries in which masks are widely used have reduced COVID-19 spread. Of course, in such studies there are many confounders and arguably countries that widely adopt masking are likely to be generally more engaged in all other aspects of nonpharmacological control of the disease (physical distancing, handwashing etc.). Moreover, there is no question that medical grade masks (N-95 and surgical masks) are very effective in reducing transmission of infection. Unfortunately, the supply of these medical masks Is limited, especially outside the medical environment. 

This has led to an increased use of cloth masks, which raises the question are cloth masks effective? The data that exist are limited but suggests they are much less effective than surgical masks. However, because of shortages of personal protective equipment (PPE) many have concluded they are helpful and better than no mask. The mayor of Toronto, John Tory (click here) and Dr. Kieran Moore (KFL&S Public Health, click here) have both indicated support/requirement for use of masks (most of which would be cloth mask) in public spaces. This is also the position of the US Centers for Disease Control. So what is the data? 

photo of Toronto mayor putting on a facemarkphoto of Dr. Kieran Moore ordering mandatory face mask wearing

Amazingly, there is only one rigorous scientific study of cloth masks that actually addresses the real question (do they prevent infection?). Most studies address a surrogate endpoint (do they lock particles?). The latter surrogate end point is relevant but it is not a sufficient assessment of whether any masks works. We wear masks to prevent infection from spreading; not simply to reduce droplet transmission. This article in BMJ Open is the only study I could find that critically addresses the relative effectiveness of cloth vs surgical masks (click here). This study focused on viral transmission in 2015; but there is updated commentary form the authors in light of COVID-19 (click here). 

In this randomized clinical trial, McIntyre et al compared cloth masks and surgical mask as a means to prevent contraction of respiratory illnesses in 14 hospitals in Hanoi, Vietnam in 2015. Their study included 1607 adult health care workers. Hospital wards were randomised to: medical masks, cloth masks or a control group (usual practice, which included mask wearing). Participants used the mask on every shift for 4 consecutive weeks. They measured rates of clinical respiratory illness (CRI), influenza-like illness (ILI) and laboratory- confirmed respiratory virus infection. The results were not favorable for cloth masks (see higher attack rates with cloth masks (black bars) than with control group or medical masks-below).

graph showing control study using cloth masks

They found that the rates of all infection outcomes were highest in the cloth mask group, with the rate of influenza-like illness 13-fold higher in the cloth mask group vs the medical mask group. Those assigned to wear cloth masks also had 6 fold higher rates of influenza-like illness compared with the control arm. Laboratory-confirmed virus infections were also higher in this assigned to wear cloth masks vs those in the medical mask group. Most of the confirmed viral infections were rhinovirus-the common cold). Penetration of cloth masks by particles was almost 97% and medical masks 44%. The authors suggested “Caution against the use of cloth masks.” They called for research to inform the widespread use of cloth masks globally. In the past 5 years the limited cloth mask research has mostly focused on the ability to reduce droplet spread (a surrogate endpoint); not on the efficacy in preventing infection. The authors of this 2015 publication were recently asked to comment on their findings in light of COVID-19 and the shortage of surgical masks (which has driven the move to cloth masks). I agree with the bottom line of the authors in their recent update for COVID-19 which can be paraphrased as concluding, cloth masks can reduce droplet emission but there are no compelling data showing they prevent infections.

Here is an excerpt from their COVID-19 article update by senior author, Chandini R MacIntyre, Academic physician The Kirby Institute, University of New South Wales. 

There have been a number of laboratory studies looking at the effectiveness of different types of cloth materials, single versus multiple layers and about the role that filters can play. However, none have been tested in a clinical trial for efficacy. If health workers choose to work using cloth masks, we suggest that they have at least two and cycle them, so that each one can be washed and dried after daily use. Sanitizer spray or UV disinfection boxes can be used to clean them during breaks in a single day. These are pragmatic, rather than evidence-based suggestions, given the situation. 

Finally for COVID-19, wearing a mask is not enough to protect healthcare workers – use of gloves and goggles are also required as a minimum, as SARS-CoV-2 may infect not only through the respiratory route, but also through contact with contaminated surfaces and self-contamination. Governments and hospitals should plan and stockpile proper disposable products such as respirators and surgical masks to ensure the occupational health and safety of health workers. This appears to have been a failure in many countries, including high income countries.”

I want to emphasize that no one locally is advocating use of cloth masks in the hospital for health care workers, rather they are being considered for use in the community and then primarily for use in indoor spaces.

So what am I going to do personally? I am going to comply with KFL&A‘s requirement and wear a mask in indoor public spaces. At Queen’s University, I will mask entering buildings and in common areas and then determine the need for a mask within that building, depending on whether I can maintain physical distancing. However, I will not be lulled by a cloth mask into abandoning physical distancing. I am mindful that in this moment in the pandemic the cloth mask is a symbol of my concern for the safety of others. I encourage more research be done to define whether cloth masks prevent COVID-19 spread; but in the meantime encourage all of us to mask in pubic indoor spaces. There is no indication for masking in outdoor spaces where physical distancing can be maintained. 

Symptomatic KHSC staff: Should KHSC staff develop symptoms consistent with COVID-19, please contact occupational health and safety and they will tell you how to proceed (ext 4389 at KGH site, or email COVIDrtwadjudication@kingstonhsc.ca). You will likely be tested at the Hotel Dieu testing centre. Do not come to work!

Kingston’s bubble may not have burst; but it is fragile (click here) (41.8 cases/100,000 population). Toronto has a rate ~10 times higher (418.8 cases/100,000 population). The prevalence in Toronto has increased every day for the past month, reflecting neighbourhood hot spots. Provincially the epidemic is in modest decline. There were 157 new cases yesterday (up 0.4% from yesterday). Ontario has had a total of and 35,068 total cases and 2672 deaths to date. The 1.0% rate of positive SARS-CoV-2 tests is unchanged compared with yesterday. 

map of GTA showing prevalence of casesanimated picture of a flame

The prevalence of cases in Toronto is still increasing daily due to over a dozen neighbourhoods which are COVID-19 hotspots, defined as rates over 1000 case/100,000 (click here), including: Moss Park, Newton Brook West, Yorkdale Glen-Park, Downsview Roding CFB, Maple Leaf, Rexdale-Kipling, Black Creek, Mount Olive, Beechborough, York University Heights, Mount Dennis, Glenfield Jane Heights, and Humber HeightsWestmount. Weston with 1706 cases/100,000 now has the highest prevalence in Toronto. The ministry has deployed public health experts, mobile testing facilities and contact tracers to deal with these “epidemics within epidemics”.

How’s Canada’s epidemic going? We have had 103,918 cases of COVID-19 in Canada and 8566 deaths (44 since yesterday) (see below). As seen below, the rate of hospitalizations and ICU admission is on a happy downward trend (top left below). The number of active cases per day is declining slowly (bar and line graphs, below right). Quebec remains the hot spot, accounting for 53% of all cases in Canada to date (below left).

graph of Canadian cases over time

Canadian aggregate data 

The epicentre for COVID-19 mortality remains our long term care facilities (LTC) (see today’s data below). The ~78,000 residents of Ontario’s LTC facilities account for less than 0.5% of the population but they account for 68% of all deaths from COVID-19! There were no deaths since yesterday in Ontario LTC centres. Canada had the highest rates of mortality in LTCs of any survey country. 81% of all COVID-19 deaths occurred in residents of LTCs (click here)! This is sad, embarrassing and requires rapid change in how we license, fund and monitor LTCs.

Testing for SARS-CoV-2 (click here): We have tested 7.67% of all Canadians (2,898,702 people). Nationally, 3.51% of all tests are positive (vs 2.52% in Ontario). Ontario SARS-CoV-2 testing is exceeding the national average for testing, with a rate of 9.56%.

The COVID-19 pandemic has exceeded 10 million cases. The pandemic hot spots are in the Americas (Brazil and USA), Russia, UK and India (click here). The global case total is 10,350,645 and the number of death is 506,827 (click here): 

America: I have children and many friends and colleagues in the United States and so I report the data below with a heavy heart (click here). The failure of leadership in America regarding implementation of a national public health response to the pandemic has been spectacular and the COVID-19 incidence is rising in proportion to this. These are concerning times for our friends, family and colleagues in America. Today I show the data as cases/million population (linear plot, 7 day average). We can only wish them well and hope that rational public health policies are enacted to try and limit the damage. Certainly we will not be seeing the border opening in the near future.

graph showing daily covid cases per million globally

My wish to you all is for a Happy, Healthy Canada Day! Stay well and enjoy a well-deserved long weekend!

picture of balloons with Canadian flag

 

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