November 16, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
1) New RNA Vaccine from Moderna (94.5% effective) (click here)
2) The storm before the calm-Sections of Canada move into the red zone as COVID-19 spikes (click here): Ontario launches new colour-coded system for dealing with COVID-19
3) Ontario’s pandemic is not well controlled with over 12,000 active case in Ontario and a 4% hospitalization rate (click here):
4) COVID-19 volumes have increased in KFL&A but we remain in the green zone (click here)
5) Canada’s second wave of COVID-19-rapidly increases, especially in western Canada
Regular reminders and updates:
- KHSC bed capacity:
- Use the Mobile Screening Tool to expedite clinic visits
- KHSC visitor policy:
- COVID-19 testing at Beechgrove Community Assessment Center: (click here):
- Increased outbreaks and deaths in Long Term Care facilities (LTC)
- COVID-19 in toddlers and young children: (click here).
- The COVID-19 global pandemic
- USA-Canada border closed until Nov 21st
1) New Vaccine from Moderna (94.5% effective) (click here)
Moderna, a US based Pharma company, has announced assessment of the interim results of a large clinical trial they are completing, using a mRNA-based COVID-19 vaccine. In an anlysis of a trial in 30,000 people (who either received the vaccine or a placebo), 95 infections were noted. 90 infections (and all 11 serious infections) occurred in the placebo group. This translates into a calculated relative effectiveness of the vaccine (versus placebo) of 94.5%, even better than the Pfizer vaccine, which was calculated to be 90% effective. The main side effects of the vaccine were fatigue, muscle aches and injection-site pain after the vaccine's second dose. The rates of these mild complications were greater than is seen with flu shots but similar to those seen with other vaccines, like the shingles vaccine. Also encouraging the Moderna vaccine can be stored in conventional refrigerators for 30 days after it is unthawed, which will make distribution easier than for the Pfizer vaccine (which requires -70C storage and thus special freezer capacity). That said, we will likely require vaccines from many companies to vaccinate billions of people so there’s room for many companies to contribute. Like Pfizer, Moderna is requesting compassionate emergency approval of its vaccine and expects to have about 20 million doses, earmarked for the U.S., by the end of 2020. Pfizer and its German partner BioNTech expect to have about 50 million doses globally by year's end. Canada has preordered these vaccines (stay tuned).
2) The storm before the calm-Sections of Canada move into the red zone on Ontario’s new colour-coded system, as COVID-19 spikes (click here) Although vaccines offer a realistic hope of stopping the pandemic, this is a hope we will realize in mid- to late-2021. For the months to come, we need to rely on good public health practices to avoid unnecessary death and suffering from the virus, which is surging in many parts of Canada.
Ontario has a new color coded system, moving from the least restricted areas (green-like KFL&A) to yellow, orange and red categories. The framework is designed to allow the government a means of modifying restrictions up or down on a regional level depending on what the data on COVID-19 infection and transmission shows. This new 5 colour system replaces the “Stage 1/Stage 2/Stage 3” framework that has guided both the province and local public-health units since May.
25 of 34 public-health units are currently in a green “prevent” stage, similar to the prior Stage 3 level of public-health measures. The most severe category is gray (lockdown), and there are no sites in lockdown currently in Ontario (click here).
Ontario’s new classification for COVID-19 restrictions (click here)
As of Saturday, Toronto and Peel Region are in the red alert level- the highest level of restriction short of a full lockdown. Oher regions are entering the orange level, such as Durham and Waterloo. Six more regions, including Windsor-Essex and Sudbury, will join the yellow alert level. Any region that moves up into a category with tighter restrictions will stay there for 28 days. Re-evaluation will be based on two weeks’ worth of data before being considered for movement into a lower category.
An excellent TVO site summarizes which areas are in which color classification and summarizes the restrictions each colour requires for various types of businesses, restaurants and sporting activities (click here).
Listing of Ontario zones by color in the new system announced Nov 3rd (click here).
These new restrictions on business will cost dearly and the government announced Tuesday that it will make up to $300 million available to businesses forced to shut down because of the restrictions imposed in hot spot regions (applications open as of November 16th) (click here).
New restrictions in response to the pandemic worsening will require each of us, health workers and lay people, to dig deep into our reserves to find the will to actively support evidence-based public health interventions that slow disease spread and save lives. Each of us needs to maintain physical distancing, wear masks in indoor spaces, wash hands frequently, get tested if one has symptoms to suggest COVID-19, get our flu shots!! and stay home if sick. We will need to base our behavior on information from trusted organizations (click here) not from politically or ideologically motivated sources (click here). People are tired of the public health restrictions and the economic and social pain this pandemic inflicts; however, adherence to public health measures is our ONLY defense until a vaccine is rolled out in 2021.
While we have been fortunate in southeastern Ontario and still have a low case prevalence, we would be wise to learn lessons from other countries that have failed to control community spread, like Switzerland and the USA. Their trajectory shows that once major metropolitan area have high COVID-19 prevalence, the disease inevitably spreads throughout the country to smaller centers and soon hospitalizations and mortality rates rise.
3) Ontario’s pandemic is not well controlled with over 12,000 active case in Ontario with a prevalence of 642 cases/100,000 population (click here)
There have been 95,496 cases in Ontario since the pandemic began. There were 1487 new cases today, up +1.6% from yesterday (click here). There have been 6619 hospitalizations, and 3371 deaths in Ontario, since the pandemic began (up 6.9% and 3.5% since yesterday, respectively). The rate of positive SARS-CoV-2 tests in Ontario remains high, having recently hit 5% and it is 4.1% today. As is evident in the graph below our second wave dramatically exceeds the first wave.
Ontario’s second wave of COVID-19 Nov 16th 2020
Thus, the pandemic is not currently well controlled with over 12,000 active case in Ontario today. Ontario’s provincial rate (642/100,000 population) has doubled in the past month and is now 6X higher than in KFL&A (103 cases/100,000 population). This is the first time KFL&A has exceeded 100 cases/100,000 population. Toronto remains Ontario’s hotspot for COVID-19 (1067.9 cases/100,000 population, up from 711 cases/100,000 population 2-weeks ago and 10 times higher than Kingston) (see map below). Ottawa is also a hot spot at 754.3 cases/100,000 population (click here).
Deaths and hospitalizations are increasing in wave 2 -on right (See graph above). There are 500 (black line) hospitalized people out of 12,830 active cases (red bars), a hospitalization rate of 3.9% (see graph below).
The majority of infections in Ontario are in young adults age 20-29; but, as can be seen from the pink bars on the graph below, we are now seeing more active infections in older people. However, most deaths are still in people over the age 60, see graph below (click here).
Neighborhood variation in COVID-19 in Toronto: Half of Toronto’s neighbourhoods are COVID-19 hotspots and have a cumulative prevalence of over 1000 cases/100,000 population and Weston exceeds a cumulative incidence of 3600 cases/100,000 (click here).
Toronto remains a collection of neighbourhoods with vastly different COVID-19 realities due to differences in social/economic, racial and health circumstances. Case load is very high in some Toronto neighbourhoods. For example, whilst Weston has had 3613 cases/100,000 residents. In contrast, the Beaches has a cumulative prevalence of 283 cases of COVID-19/100,000 residents. When one examines recent cases (i.e. those diagnosed since Oct 23rd), case prevalence is lower-although still concerning-ranging from 13 cases/100,000 residents, in High Park-Swansea versus 959 cases/100,000 residents, in Maple Leaf (See map below).
4) COVID-19 volumes have increased in KFL&A but we remain in the green zone (click here): There have been 15 new COVID-19 cases in our region since my note on Thursday. The total number of cases since the pandemic began is now 214. Currently there are 33 active cases locally, up from 6 last Monday. All local COVID-19 patients are recovering in the community (see update from KFL&A Public Health). There are 3 outbreaks in KFL&A, one in a school, one in a business and one in a nursing home. Almost all local cases of COVID-19 have some connection to contact with people from Toronto or travel to Toronto. Caution should be considered in considering travel to and from Toronto, our provincial hotspot.
COVID-19 in KFL&A Nov 16th 2020
The KHSC lab has performed 2127 COVID-19 tests in the past 4 days with 20 positive tests. Three positive tests were from Kingston, 12 from the Kawartha area and 5 from LTCs from around Ontario. There are no hospitalized patients at KGH. There were 12 positive tests from our community testing centers. Our new online system, called Coconut, launched today.
5) Canada’s second wave of COVID-19-rapid increases in new cases in western Canada: We have had 297,550 cases of COVID-19 in Canada and 10,963 deaths (see below) since the pandemic began. There are 48,996 active cases in Canada today, up over 1100 from yesterday. 15.9% of all cases are now active cases. Canada has done over 11.5 million tests and has a cumulative test rate positivity (since the pandemic began) of 2.57%. Ontario remains the province with the highest amount of testing and has a cumulative positive test rate of 1.68%, although it is much higher lately (4.1%). Note the increasing % of new cases in the bar graph on top below. Rates of infection are rapidly rising in all Western provinces (BC to Manitoba) whereas they are rising (but more slowly) in Quebec and Ontario). Rates of new infection are low in all Maritime provinces. There are new outbreaks in the North in indigenous communities in Nunavut (click here) and on Hudson Bay.
KHSC bed capacity: Resuming elective admissions but beds remain in short supply
Kingston General Hospital (KGH) has 71 beds available, up slightly from Thursday (when it was 71 beds). Not all of these beds are in locations that can accommodate an adult COVID-19 patient, however. Elective inpatient care has resumed but with the rising wave of COVID-19 in Ontario it is uncertain how long this can be sustained. I urge colleagues to see patients in person that require face to face visits (it remains safe to do so). When in person visits are not possible, we offer video visits (using REACTS and OTN), telephone visits and e-consults (using our asynchronous, online consultation for family doctors). While both elective admissions and elective clinic visits are available to us, let’s make hay while the sun shines!
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”: One way to safely expedite entry of patients into our facilities is to have all patients complete our pre-screening questionnaire before their clinic visit. This will screen out people who are sick and expedite entry to the facility for everyone. Reducing lines waiting to enter the clinics will be particularly important as colder weather arrives. 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.
KHSC visitor policy: One of the hardest aspects of COVID-19 care in the hospital is the need to restrict visitors to ensure we don’t import COVID-19 into the hospital. A very few cases of COVID-19 can paralyze the hospital, particularly if they are brought in by visitors and then spread undetected. All details on the policy can be found using this link (click here).
COVID-19 testing at Beechgrove Community Assessment Center: (click here): All COVID-19 test must be scheduled appointments (versus walk in). Our new online system, Coconut, launched today and will assist in contact tracing. Appointments can be scheduled by telephone or by our new Eventbrite on line scheduling system. Before booking a test, individuals should complete the online tool to determine whether they qualify for testing (click here). The Beechgrove Complex is south of the King St. West/Portsmouth Avenue intersection. Signage will direct people through the Complex to the Recreation Centre building at 51 Heakes Lane for walk-in testing. 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.
We began testing staff at Beechgrove instead of Hotel Dieu 2 weeks ago. 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.
Increased outbreaks and deaths in Long Term Care facilities (LTC): We have 4060 LTC beds in KFL&A. As discussed in many prior notes, most COVID-19 deaths occur in people who are not only old but who are also frail and live in nursing homes and long term care facilities (LTC). As of today, the 2081 deaths in nursing homes (up 33 cases from Thursday) account for 61.7% of all deaths in Ontario, click here. In the last 3 weeks the rate of death amongst LTC residents continues to increase daily! There is one new outbreak in a regional seniors residence, the Trillium Care Community Centre, where 1 infected staff member was recently identified on screening testing (click here).
Outbreaks in nursing homes usually start with a person in the community (health worker or family) acquiring the infection and importing it into the facility. Thus, protecting LTCs is best done with a combination of reducing community spread of COVID-19 and ensuring single occupancy rooms in LTCs (as well as appropriate pay for PWS workers, provision of PPE and rapid testing capacity).
COVID-19 in toddlers and young children: (click here).
Fortunately kids remain much less likely to be infected by SARS-CoV2 and when they are infected they usually become much less ill (click here). The vast majority of upper respiratory tract infections in kids in Ontario are caused by other viruses, like rhinovirus and RSV. Thus, health policy makers and parents of young children should recognize that while children are not immune from COVID-19 infection, infections are relatively uncommon and outcomes are usually excellent for those who are infected. Nonetheless, we are about to prioritize children of healthcare workers for testing at KHSC so we can return the parents to work when children with symptoms (which will rarely prove to be COVID-19) are sent home from school or daycare.
Children are usually infected by an adult, usually in their home, rather than by other children. The number of cases in school age children (which includes teenagers) has increased to 1913 cases up from 1794 on Thursday and double the number from 3 weeks ago (985 cases).
Amongst younger children and toddlers COVID-19 remains relatively rare. In Ontario’s 5,500 licensed child care centres and over 120 licensed home child care agencies there is a very low COVID-19 burden (see table ). The rise in cases has been modest in these young children. 322 toddler age children have now been infected to date, up from 303 on Thursday and 209 cases 3 weeks ago.
The COVID-19 global pandemic exceeds 1.3 million deaths and over 54 million cases (up 2 million from Thursday): There are now 54,563,236 cases globally and there have been 1,319,882 deaths. The number of cases has increased over 3-fold the beginning of August, 2020 when there were 16,296,790 cases globally. The pandemic hot spots are in the USA, India, Brazil, and Russia (click here). The USA with 11,065,237 cases and 246,526 deaths tops the COVID-19 list and accounts for ~20% of the global pandemic, while only accounting for ~4% of the world’s population. India has the second largest number of cases (see global map of COVID-19 Nov 16th-below).
Global COVID-19 Nov 16h 2020
American data of COVID-19 testing: In contrast with Ontario’s 4.1% rate of positive tests, the USA has an average rate of positive COVID-19 tests of 10% (a dramatic rise from October) (click here). Positive rates of testing are just over 12.6% in Illinois, 8% in Florida and 6.6% in New Jersey.
The US-Canadian border will remain closed for routine travel at least until the end of November (click here).