March 1, 2021 - 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

| 1 March 2021

All patients admitted to KHSC will undergo Covid-19 testing

1) Vaccination in Ontario: What’s the plan? (click here)

2) Vaccination of frontline health care workers at KHSC: We expect to have ~2000 people vaccinated by the end of the week-KUDOS to our amazing vaccine team!

3) All about COVID-19 Vaccines:

Updated FAQs about vaccination including new FAQ 1): Which COVID-19 Vaccines have been approved by Health Canada?

4) Ontario crosses the 300,000 cumulative case mark and infection rates have stopped declining with a 7% increase in new cases last week and a daily new case rate of 1062 yesterday. All 3 variant viruses (UK, Brazilian and South African) are present in Ontario click here) (click here)

5) Canada’s COVID-19 epidemic continues to improve: There have been 866,503 total cases with 2,307 new cases yesterday. There were no decreases in rates of new cases but active cases were down (-5%) as were hospitalizations (-9%) and deaths (-13%) (click here) (click here).

6) Improvement in COVID-19 in Ontario’s Long Term Care facilities (LTC): Vaccines work and weekly death rates have declined from >100/week to 10/week!

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1) Vaccination in Ontario (click here)

For a summary of Ontario’s COVID-19 vaccine plan I refer you to this government of Ontario resource (click here). I will not pile on; but in general the opinion is that we are not proceeding fast enough or with enough clarity or urgency. Counterbalancing that, it is clear that the main problem is lack of vaccine supply. The first graphic shows the progress to date: essentially 5% of the population have had at least 1 vaccine dose.

table with numbers and image of needle in arm

The next graphic shows the plan for the other 95% of the population. It indicates that by July we expect to have 5.8 million vaccines delivered. We are currently in Phase 1.

Vaccines are a) not approved for people under agree 16 years (~3 million) and b) ~10% of the population will likely refuse the vaccine (a guess but this could be ~1.4 million people). This Ontario plan predicts that ~6 million of 10 million eligible/willing adults will be vaccinated by the end of July (60%). After July ongoing vaccinations are planned. This plan could accelerate with more vaccines (especially if we approve and receive the one shot J&J vaccines which simplify and accelerate the vaccination process).

2) Vaccination of frontline health care workers at KHSC: We expect to have ~2000 people vaccinated by the end of the week-KUDOS to our amazing vaccine team!

This week we will continue vaccinating our health care workers. There were over 1000 people vaccinated at KHSC last week. We estimate a similar number of staff, trainees and faculty will be vaccinated this week. This would mean ~2000 worker would be vaccinated by weeks end if all goes well.

The order of vaccination is a sensitive subject with so many people waiting. While no order of distribution will satisfy everyone, Canada’s recently improved vaccine pipeline, vaccination will quickly move to include all frontline health care workers, vulnerable populations and then the rest of society. The order of vaccination is based on guidance from two documents, “Guidance for Prioritizing Health Care Workers for COVID-19 Vaccination”(click here) and Ontario’s “Ethical framework for COVID-19 vaccination distribution” (click here). These guidelines determine vaccine order based on probable vulnerability to the virus (be that personal risk or risks to patients you interact with) and on exposure risk. This is why people who live in or work in long-term care (LTC) facilities were the first to be vaccinated. LTC sites account for almost 60% of all COVID-19 deaths in Ontario. Since vaccinations have been administered to the vast majority of residents and workers in LTCs, rates of infection and mortality have shown huge decreases. While we could each envision some other order of vaccine administration this is a futile exercise at this point.

Your order in the KHSC vaccine queue is not dependent on whether you are staff, faculty or trainee; rather it is based on where you work and the associated provincial risk ranking. All who work in an area prioritized for vaccination (be they employees, physicians, learners, contracted staff or volunteers who regularly work in or provide care in an area) will receive an vaccine invitation at roughly the same time. Check here to see the order of vaccination for people working in KHSC (click here).

Once your group is ready to be vaccinated you will get an email inviting you to accept your vaccine. The invitation takes you to a site where you select an appointment time. You will then be asked to show up at the vaccination site (Burr gymnasium) 10 minutes before your vaccine time. Please make sure you check your KHSC email as the vaccine team will be sending out appointment invitations by email and appointments are booked on a first come first serve basis for people within your vaccine group.

For physicians the notice is sent to their “preferred” email. Please ensure the hospital has you correct email address (this should be listed on you annual credentialing document and updated each year at reappointment if it changes).

The KHSC COVID-19 Vaccination Clinic is located at KHSC’s Kingston General Hospital site George St Entrance.

Instructions:

Please wear your mask.
Bring your workplace ID to verify eligibility upon arrival
Also Bring your:

Completed paper consent form
Completed Pre-screening
Health card - you are required to bring your health card or bring another form of a government issued-photo ID such as a driver’s license, passport, Status Card or other provincial health cards.

Please arrive on time but do not arrive more than 10 minutes before your appointment.
Give yourself 30 minutes to complete the vaccination process.
Wear a loose-fitting top or a t-shirt so that the health care provider can easily access your arm for the vaccination

A few reminders about the reality of the vaccine program. The rate of vaccine roll out is largely a function of vaccine supply, rather than our capacity to vaccinate, and this will be true at least for the next 1-2 months, despite an improving supply of vaccines. I have heard concerns from a number of high-minded physicians about concern about the ethics and optics of them receiving a vaccine before others (staff, co-workers, family members etc.). This angst is understandable. For those in the vaccine vanguard who are concerned about “going early” here is my advice:

We don’t control the order of vaccination and so if you are in the first group you should definitely take the offered vaccine. Everyone will understand that you did not lobby for a vaccine; you were assigned because of your role/risk etc. In fact by following protocol you are serving as a positive role model for people, indicating your confidence in the vaccine and your willingness to abide by Ontario’s vaccine plan.
Once we vaccinate all the people in your priority group we will then be authorized to go to the next priority group. Thus, by getting promptly vaccinated you are speeding things up for those in the next highest priority group.
While you can decline vaccination you can’t give your vaccine to someone else. Therefore it makes no sense to decline vaccination based on the understandable desire to “help others”.
Canada’s vaccine supply is ramping up quickly and we will soon have adequate vaccine supply to vaccinate people in tiers 2-8 of Ontario Health’s vaccine hierarchy.
In 2021 all people willing to be vaccinated will be vaccinated! No person or government has a perfect strategy. Let’s celebrate the success in creating a robust local vaccine program and not focus too much on the order in which these vaccines are rolled out.
It is our responsibility to promptly respond to the call to get vaccinated (i.e. once appointments begin please change your schedules to meet the vaccination schedule). Vaccination requires only 30 minutes your day and it would be impossible to customize schedules for every practitioner.

3) Here are answers to some updated FAQs with answers to common questions about the COVID-19 vaccines.

FAQ 1) Which COVID-19 Vaccines have been approved by Health Canada? Currently Canada has 3 approved vaccines: Pfizer, Moderna, and Astra-Zeneca (as of last week). The Astra Zeneca vaccine was approved on Friday and may arrive as soon as Wednesday (click here). Canada is expecting 445,000 doses of this vaccine this week. The vaccine appears to prevent COVID-19 spread and severe COVID-19 pneumonia and death; however, it has the lowest effectiveness overall (62% protection).The J&J vaccine was just approved by the FDA in the USA (click here). It has not been approved in Canada yet but this is expected to occur in the next 2-3 weeks. The J&J vaccine has several advantages. In a study with people in 3 continents one dose of J&J was 85 per cent protective against the most severe COVID-19 illness and the safety profile was as good as other vaccines. The J&J vaccine is a single shot vaccine (unlike two shots for Pfizer and Moderna). In addition it can be stored in a simple office refrigerator, allowing it to be rapidly deployed in the community. The bottom line: All approved vaccines are protective against severe adverse outcomes and I would advise you to take the first vaccine you are offered!

FAQ2) Does the vaccine work against new variants (mutations) in the SARS-CoV2 virus? Short answer is a qualified YES. The vaccines work albeit not quite as well for the variants. In the 144,000 participants in all randomized clinical trials of vaccines to date, those receiving any active vaccine had only 3 cases of severe COVID-19 (vs 37 in the control group). There were no deaths in people who were vaccinated with any of the vaccines versus 5 deaths in the control group. Even though absolute protection is slightly less for UK and South African variants the vaccines (including the AstraZeneca vaccine and J&J) prevent serious adverse outcomes (like hospitalization and death). Thus, despite variant viruses the vaccines are lifesavers!

FAQ 3) I’m on a blood thinner, can I be vaccinated for COVID-19? Short answer YES. Here is a more detailed answer from a Canadian agency with expertise on the use of blood thinners, Thrombosis Canada.

memo from Thrombosis Canada re vaccinations and blood thinners

FAQ 4) 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 (which is why you will be monitored for this period of time post vaccine). There were also 83 cases of non-anaphylaxis allergic reaction after Pfizer-BioNTech COVID-19 vaccination with symptom onset within a 0–1-day risk window. Most (87%) of these allergic reactions were classified as nonserious. Thus, 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). The incidence of anaphylaxis is lower still with the Moderna vaccine.

The adverse effects of the COVID-19 vaccines in clinical trials are similar in vaccinated people vs people who got a placebo-saline injection except for: local pain at the vaccine site and increased muscle ache and headache, all of which were more common with the vaccine but were short-term (see below). This is a very good safety profile relative to other vaccines.

table listing side effects for Pfizer vaccine vs placebo

The CDC does advise against the use of the two mRNA vaccines for a very select group of people with the following allergy histories (click here):

Severe allergic reaction (e.g., anaphylaxis) after a previous dose of an mRNA COVID-19 vaccine or any of its components
Immediate allergic reaction of any severity to a previous dose of an mRNA COVID-19 vaccine or any of its components (including polyethylene glycol [PEG])*
Immediate allergic reaction of any severity to polysorbate (due to potential cross-reactive hypersensitivity with the vaccine ingredient PEG)*

FAQ 5) 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).

The British Society for Immunology recently issued a statement indicating that vaccination is safe in immunosuppressed people (click here), albeit the resulting immune response may be weaker. They remind us that because there is no virus in the vaccine there is absolutely no risk of acquiring COVID-19 from the vaccine. 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). 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. Overall these data are 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.

FAQ 6: How long can I wait after my first dose to get a second vaccine dose? 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 bottle

FAQ 7: Can I get COVID-19 from the vaccines? This answer is simple-NO! None of the approved vaccines in Canada contain the virus itself. They do not contain live virus; they do not contain dead virus. Canada’s approved vaccines (from Pfizer and Moderna) contain only the messenger RNA (genetic code) to allow you cells to make the viral spike protein which then triggers your immune cells to build anti-spike antibodies which protect you. The Astra Zeneca vaccine is much the same but delivers the SARS-CoV-2 spike protein gene via a chimpanzee adenovirus-vector. Again, there is no virus (not dead; not alive) in this vaccine (click here). So, while you might get a sore arm or a fever from vaccination this is just your immune system responding as it should; there is no chance of getting COVID-19. Obviously one could contract COVID-19 around the time of vaccination the normal way, before the vaccination’s protection develops (i.e. in the first 2 weeks after vaccination).

FAQ 8: Are vaccines safe? Yes, serious adverse effects of vaccines are rare (occurring in only 167 of 1.4 million Canadians vaccinated). Most people get (at worst) sore arm at the injection site, fatigue, or fever, all signs the immune system is being activated. Based on the clinical trials and experience in millions of people who have been vaccinated world-wide we can be reassured of vaccine safety and efficacy. All the side effects (called adverse events and abbreviated AEFI) are tracked and reported by the government of Canada (see below). (click here) (no update in the past week).

number graphic re side effects from vaccine

5) Ontario crosses the 300,000 cumulative case mark and infection rates have stopped declining with a 7% increase in new cases last week and a daily new case rate of 1062 new cases yesterday and a further 3% decrease in hospital rates. All 3 variant viruses (UK, Brazilian and South African) are present in Ontario click here) (click here)

coloured map of Ontario with cities labelled

The COVID-19 epidemic is markedly improved in Ontario (see below) with new case rates below 1100/day. The rates of new and active cases have risen slightly compared to last week, 7% and 1% respectively; but the provincial death rate is down 29% (likely due to the effective LTC resident vaccination program). Ontario’s test positivity rate has plateaued at 2.3% (Feb 25^th data).

COVID-19 second wave is at a new plateau (but not declining further vs last week) March 1st, 2021 (click here)

5) KFL&A COVID-19 rates remain amongst the lowest in the province with 21 active cases in our region (see update from KFL& A Public Health)The total number of cases in KFL&A since the pandemic began is 720, not counting the prison outbreak. This is up 11 cases from last Monday. There has only been one death of a KFL&A resident since the pandemic began. There are 14 active cases in KFL&A, 7 less than last week There are a total of 44 active cases in South Eastern Ontario, up 13 from 2 weeks ago. Last week we ran 5597 tests run in our lab and 48 were positive. Our test (+) rate is thus 0.9% (up from 0.5% a week ago). There remain 3 COVID-19 patients hospitalized at KGH. As you can see in the graphic below we have 3 cases in the area that are caused by variants of concerns (possible SARS-CoV-2 mutants).

2 yellow bar graphs on top of each other with a pie graph below

COVID-19 in KFL&A March 1st 2021

5) Canada’s COVID-19 epidemic continues to improve: There have been 866,503 total cases with 2,307 new cases yesterday. There were no decreases in the new case rate but active cases were down (-5%), as were hospitalizations (-9%) and deaths (-13%) (click here) (click here).

green and blue map of Canada and northern USA

There have been 22,006 COVID-19 deaths thus far and a cumulative national case mortality rate of ~2.04%. There are currently 1,9992 people in hospital across the country with COVID-19, 57 less than yesterday. Canada has performed 25,003,952 million COVID-19 tests with a cumulative test positivity rate of 3.46%. There is a further gratifying 9% decline in weekly ward and ICU hospitalizations (see below). We are now seeing a large reduction in deaths (13% in the past week).

Improvement in wave 2 continues: March1st 2021 (click here).

There are several new hot spots and related brief lockdowns. PEI has had a 17 new cases in 5 days (click here) (see below) and as a result is in a 3 day lockdown.

coloured line graph showing increase in PEI cases

PEI COVID-19 outbreak-March 1^st 2021

The outbreak of COVID-19 in Newfoundland is resolving with intensified public health measures (see below). These two provinces are a reminder that with <5% of Canadians vaccinated, the vast majority of the population remain as susceptible to COVID-19 as they were a year ago.

soured lline graph showing increase in Newfoundland cases

Newfoundland COVID-19 outbreak-March 1^st 2021

Rates of infection remain at a low plateau in all Western provinces (BC to Manitoba) as a result of introduction of more aggressive public health measures. Rates in Ontario and Quebec (home to almost 63% of all Canadians) continue to experience a lockdown-induced decline. Infection rates remain low in the North.

Canada’s vaccination roll-out update-million person vaccinated mark passed (click here): Canada’s roll out of vaccine has been slow; but vaccine supply has markedly improved this week. To date, 1,911,880 doses of COVID-19 vaccines (including both Moderna and Pfizer-BioNTech) have been delivered. Thus far, 78.3% of delivered doses have been administered. 1,385,004 Canadians have received at least one dose of an approved COVID-19 vaccine (see below). 526,876 Canadians are fully vaccinated (click here).

map of Canada with provinces labelled and number of vaccines administered

Number of vaccinations in arms as of March 1^st, 2021

7) The global pandemic:

There have been 114,208,352 cases and 2,532,948 deaths since the pandemic began. Active case rates have been declining since the beginning of 2021 (click here) (see orange graph of daily case rates, orange bottom right). Daily deaths are also declining (see white graph below).

world map with ranking of countries with most covid cases listed on the side

Global COVID-19, March 1^st, 2021: The number of active cases (salmon dots on map) is declining globally (orange graph on right)

black and white bar graph showing decline in daily deaths from covid-19

Decline in daily death rates globally beginning in 2021

The USA, with 28,606,177 cases and 513,092 deaths has roughly the same total number of cases as the next four most affected countries combined (India, Brazil, Russia. United Kingdom). The USA has accounted for ~25.2% of the global pandemic but things are improving rapidly in the USA, due likely to natural immunity, vaccine acquired immunity and better adherence to public health measures. Americahas seen a continued reduction in positive test rates for over a month (with rates now at 4.5%, the lowest since June 2020, click here; see below).

bar and line graphs showing decline in USA covid cases

Continued improvement in positive test rates in the USA (currently 4.5% positive), March 1^st 2021

7) Improvement in COVID-19 in Ontario’s Long Term Care facilities (LTC)-evidence vaccines working:

three senior citizens sitting around a table wearing masks

Most COVID-19 deaths occur in people who are not only old but who are also frail and live in nursing homes and LTC facilities. While LTC residents account for only 5.3% of all cases in Ontario, click here, they account for 53% of all 6944 deaths in Ontario. As of today, the 3,744 deaths in nursing homes (up 10 deaths in the past week) account for ~57% of all deaths. There are ~ 80 active COVID-19 cases in LTC residents and 179 active cases in LTC staff. These numbers are rapidly and massively declining each week for the past 4 weeks, which is very encouraging! For example a month ago we were seeing death rates of >100/week; now it is 10/week; still too many but heading in the right direction rapidly. These statistics (see below) show the beneficial impact of the province’s decision to prioritize its limited initial vaccine supply of health care workers and residents of Ontario’s LTCs.

Ontario LTC’s are improving rapidly because of vaccinations

Regular reminders

KHSC bed capacity: Bed capacity is adequate with 60 beds available (down 21 from last Monday) and good ventilator capacity (47 units). Critical care beds are never plentiful but there is still better reserve than we have seen in the past month (see below). Medicine remains busy with our doctors caring for people in 187 beds, not including ICU beds on Davies 4 staffed by the Medicine program.

We are committed to providing care to the 99.9% of patients in SE Ontario 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. We 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!

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”: All patients should complete our pre-screening questionnaire before their clinic visit. This will screen out people who are sick and expedite entry to the facility. 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.

finger scrolling on iPhone screenshot of KHSC [[re screening app

KHSC visitor policy: We continue to strongly discourage visits from people coming from Red Zones, like Toronto. Details on our visitor policy can be found using this link (click here). This is one of the hardest aspects of COVID-19 care in the hospital. Nurses in particular bear the burden of fielding numerous requests for visitation and while many requests tug on the heart strings we need to keep our hospital safe so it can function for the good of all residents. There are exceptions made to allow visitors under exceptional circumstances, particularly for palliative or dying patients. These exceptions are usually for a single visit. Our policy is necessary to prevent importation of infection to the hospital which would impair our ability to care for all patients. A very few cases of COVID-19 can paralyze the hospital, particularly if they are brought in by visitors and then spread undetected.

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). 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 getting nasal swab covid test

three young boys dressed up as doctors wearing white coats and stethoscopes around their necks

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.

COVID-19 in toddlers and young children: (click here). It has remained true throughout the pandemic that children in general are less severely affect by the virus and young children are somewhat less infectious (perhaps because they are less sick). Rates of infection are very low in preschool children.

The situation in Ontario schools remains stable. The good news is the reopening in the 7 areas where it was permitted has not resulted in major increases in new cases. Below is the new baseline report for school age children in publicly funded Ontario schools. School boards report every weekday from Monday to Friday. In person classroom education is back in Toronto, Peel and York. With more kids back in school we are seeing more infections (although not at alarming rates). There have been 6043 students with COVID-19 since the pandemic began with 715 new cases in the past 2 weeks. This is double the number of last week’s new case rate, consistent with more young people being back in school.

four teenagers sitting on a bench using iPhone iPad and reading a book

Here are the parallel data from licensed child care facilities in Ontario-where there have been 1371 children infected since the pandemic began, 169 new cases in the past 2 weeks (unchanged from last week’s report).

group of young children sitting on a classroom floor

Stay well!

March 1, 2021 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

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March 1, 2021 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program