June 5, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
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) and no COVID-19 cases in KHSC. The running total for the epidemic remains at 63 COVID-19 cases in the KFL&A region and only 1 outpatient case is active. We did 506 SARS-CoV-2 tests yesterday-a huge increase in test volume! 3 tests were positive, none from Kingston. The positive test rate in KFL&A remains at 0.5% (vs 3.7% in Ontario).
Our PPE supply is stable with 3 weeks reserve, at the current level of activity. However, we are awaiting a decision from the province re: our request for some local exemption/modification of their recently announced proposal that Ontario’s hospitals adopt a universal masking policy. While our local epidemiology supports our current policy, we are prepared with a plan to alter our masking policy, should we be required to do so. We will announce the KHSC plan on Monday.
Our outpatient volume is currently 33% of baseline and we are rapidly increasing capacity toward a new service level, which will be ~50% capacity. This together with a ramp up of elective procedures (surgery, cardiac, endoscopy) will begin to address the care deficit for the 99% of patients, a regular topic in this note. To have permission to ramp up, KHSC must attest to the MOH that we have reserve capacity to deal with a second peak in COVID-19 (meaning adequate supplies, available beds, adequate staff etc.) and that we can ramp down, within a week if required.
Care of the 99%-the financial implications of nonpharmacologic interventions to flatten the curve: I wrote yesterday about the intrinsic link between health and financial consequences of the pandemic. This was inspired by Dr Vivek Goel’s interview (click here). Here is a recent sobering paper from Bloomberg on the financial impact of COVID-19 (click here).
This article summarizes global economic consequences of shutting down societies in our battle to contain the spread of COVID-19 through nonpharmacologic means (physical distancing, closing of nonessential services, closing of borders, schools and daycares etc.). The impact is greater than initially predicted. Behind the numbers (contraction of Gross Domestic Product-GDP), and rise in unemployment, is tremendous human suffering, sadness and food insecurity. When it comes to the predicted fall in GDP (a measure of our economic strength) you can see Canada is predicted to do relatively poorly with an ~8% fall. More concerning is that all economies in this graph are contracting, with the exception of China and Indonesia.
Likewise, Canada’s predicted rate of unemployment is substantial (6-7%) , although not as bad as seen in Spain and Italy.
I look at these numbers as an opportunity for Canada to reinvest in our economy and build a supply chain that is less dependent for critical materials on China, India and the USA. Secondly, these economic harbingers of recession serve to counterbalance to the tendency to keep society due to fear of COVID-19. This does not mean we should reactivate fully tomorrow; however it is powerful evidence of the cost of the status quo. We need to gradually ramp up and respond rationally to the inevitable second wave of COVID-19 with a calm knowledge that we need to reactivate the economy.
Screening for out of province travel: All people entering the facility are asked if they have traveled out of province. 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.
COVID-19 screening of asymptomatic health care workers: 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.
How’s the epidemic going? To date there have been 94,070 cases of COVID-19 and 7,652 deaths in Canada (see below). As you can see the number of daily reported cases continues to decrease (bottom, 2nd from right below. I have included at the top left the Ontario numbers. The disease remains most prevalent in Quebec (above).
While the Ontario COVID-19 incidence curve has flattened we need it to actually collapse (meaning daily new cases would have returned toward zero). The Ontario story is intimately related to the continued persistence of the epidemic in Toronto, where things are not so rosy. In Ontario as a whole cases are up 1.2% from yesterday to a total of 29,747 cases since the pandemic began. However, Toronto has a rate >11 times higher (350.2.4 cases/100,000 population) than Kingston (29.1 cases/100,000), and this rate continues to increase daily (see below).
Toronto’s COVID-19 hotspots: think provincially; act locally In Toronto there is more granular epidemiology emerging and it is becoming clear (based on a story in the Globe and Mail by Kelly Grant today) that poorer neighbourhoods, like Crescent Town have much higher incidence of COVID-19 than the city as a whole. These hot spots require focused attention to ensure testing and contact tracing are rigorous if the Toronto curve is to be flattened. Some pockets have very high infection rates, like north Etobicoke, where the rate is 700 cases/1000,000. This means we will need to do better to deploy resources to microregions which are disproportionately affected and the provincial government will need to develop a nuanced, regional approach to the epidemic, which is a challenge for a large bureaucracy.
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 ~71% of all deaths from COVID-19! There were 13 deaths since yesterday in Ontario LTCs.
Testing for SARS-CoV-2 (click here): We have tested ~5.1% of all Canadians (1,875,334 people) and are at a slightly higher same rate of testing in Ontario (5.59%).
To see where Canada stands amongst nations in the COVID-19 pandemic, click here. The global case total is 6,682,531 and the number of death is up to 392,321. Here is a list of the most affected countries: USA, Brazil, Russia and UK. America remains in a league of its own (sadly), with ~28% of all reported cases in the world! When you compare the red dots (the size of which reflect the number of infected people) one gets a graphic sense of the size of the epidemic in the USA vs Canada. This has major ramifications for opening of the US-Canadian border.
A revised reminder for people in the community (last updated May 27th)
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.
Fake News on HYDROXY (click here): You may have been following the fuss about hydroxychloroquine (or as the great orange demagogue calls it, HYDROXY). First this drug, which has long been use for malaria and rheumatoid arthritis, was found to have antiviral properties, and decreased infection in cells by SARS-CoV-2. It was touted as promising. Then President Trump took this evidence and for a variety of reasons began to perform a one man infomercial for use of the drug as a preventative medicine for COVID-19, claiming he took it himself. This raised eyebrows and likely biased people against the drug. Then a few studies suggested there was cardiac toxicity from hydroxychloroquine, particularly at high doses. Then a paper appeared in the journal The Lancet (click here) claiming the drug caused a substantial increase in heart rhythm related deaths. This appeared to be a death blow to the inclusion of this drug, in SOLIDARITY, a global clinic trial of promising anti-COVID-19 drugs. However, it turns out this paper was based on data from a company called Surgisphere, which could not provide compelling answers to questions about its purported findings, leading to the paper being retracted! Critical readers found “many red flags in the Lancet paper, including the astonishing number of patients involved and details about their demographics and prescribed dosing that seem implausible”.
Similar concerns were raised by a similar paper from this group in the NEJM (click here). So in the end we are in the sad position that after 6-million cases of COVID-19 we don’t know if hydroxychloroquine is effective and safe as a therapy. We do know we need to conduct science free of meddling by politicians, some with financial interests at stake, and with robust peer review and data integrity. Hopefully we will eventually learn the truth about HYDROXY from the SOLIDARITY randomized clinical trial-stay tuned and remain a critical consumer of published data.
TGIF message: Here is a reminder sent to me by Dr. Janet Lui that people appreciate the great work you all are doing every day. This stone, by the Watkins 2 entrance, features a lego health care worker rocking some cool orange scrubs! To my fellow health care workers: Thanks for all you do to make KHSC and Queen’s a great place to provide patient care, teach and do research. Our patients are lucky to have you and I’m grateful to have you as colleagues in these challenging times.