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


 

Headlines

1) How likely is there to be someone at a gathering of 10 people that is infected/can transmit COVID-19?

2) Potential new Astra Zeneca vaccine is effective in producing protective neutralizing antibodies in the elderly (click here

3) KFL&A asking restaurant workers to be tested after several recent cases (click here)

4) Ontario’s pandemic is not well controlled with over 12,800 active case in Ontario and a 4.1% hospitalization rate (click here): 

5) COVID-19 volumes have increased in KFL&A but we remain in the green zone (click here)

6) Canada’s second wave of COVID-19: Over 300,000 total cases and a rapid spike in infection in western Canada:

7) The COVID-19 global pandemic exceeds 1.3 million deaths and over 56 million cases (up 2 million from Thursday) (click here):

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). 

1) How likely is there to be someone at a gathering of 10 people that is infected/ can transmit COVID-19?

Would you feel safe getting together with 10 asymptomatic friends? Recent data, based on local disease prevalence, suggests that the answer to this question should depend a lot on where you live (beyond details that are more often taken into account when making decisions, such as personal preference and details about the circumstances/space of the gathering). If you want to meet in Prince Edward county the odds of a transmitter in your midst for a meeting of 10 people is only 0.3% (see table below). However, the same gathering in Kingston carries a higher risk that you have a source of infection amongst you (1.5%). That same group meeting size in Toronto carries a risk of to 5.7% whilst in Peel it is even higher, at 11.9%. 

As the table below shows, no matter where you are in Ontario, assembling in larger groups increases the odds of an infectious person being present. Getting together in groups over 25 would be playing with fire in some regions; whilst gatherings of 100 have a high risk of transmitting infection almost everywhere in Ontario. These data remind us of the major local variation in risk of infection. The table is also a compelling visualization of the risk in assembling in larger groups.

table showing the likelihood that someone at your gathering has covid per city

2) Potential new Astra Zeneca vaccine is effective in producing protective neutralizing antibodies in the elderly (click here) (www.thelancet.com Published online November 19, 2020 https://doi.org/10.1016/S0140-6736(20)32466-1

headline of new covid-19 vaccine from Astra Zeneca testing

This Phase 2 clinical trial reports the results of a novel chimpanzee adenovirus-vectored vaccine from Astra Zeneca. This vaccine uses a different method of creating immunity to COVID-19 versus the RNA vaccines developed by Moderna or Pfizer. The goal of this study of 560 people was to assess the safety and effectiveness (humoral and cellular immunogenicity) of single-dose and two-dose vaccinations in adults, particularly in those older than 55 years. The study was performed at 20 centers in the UK. The study is important because it recognizes that it is older adults who are most susceptible to complications from COVID-19. The study included 240 people aged 70 years and older, which is the age group that is most at risk from COVID-19. 

The vaccine was safe, although it commonly produced minor adverse effects (injection-site pain, feeling feverish, muscle ache, headache). Interestingly these adverse effects were less common in those over 70 years of age. While most people had some minor adverse local reaction to the vaccine the13 serious adverse events were unrelated to the study vaccine. By 14 days after the boost dose, 208 (>99%) of 209 participants that received both the vaccine and a booster dose had significant neutralising antibody responses. T-cell responses peaked at day 14. 

Conclusion: Immunisation with this vaccine (called ChAdOx1 nCoV-19) results in development of neutralising antibodies against SARS-CoV-2 in almost 100% of participants, including older adults without severe comorbidities. Antibody levels were higher in people who received a booster dose. The production of neutralizing antibodies is thought to be protective and as the graph below shows, antibodies were produced in all age groups, even the elderly who most need protection. However, this is a phase 2 study and ultimately, licensure of this vaccine will rely on the demonstration of efficacy in preventing COVID-19 and safety in the Phase 3 studies which are ongoing in the UK, Brazil, and the USA. 

graph showing outcome of vaccine testing

Production of neutralizing antibodies after Astra Zeneca adenoviral vaccine

3) KFL&A asks restaurant workers to be tested after several recent cases (click here)

In just the past two weeks, several restaurant workers have been infected with COVID-19. This includes employees at two McDonald’s locations in Kingston, an A&W and two Tim Hortons, one at 671 Cataraqui Woods Dr. and the other at 1396 Bath Rd. The public health unit is reminding restaurant owners to have their staff tested and if a test is positive they are required to notify public health who will then coordinate the timing of testing for any potential contacts.

photo of KFL&A sign outside their building

4) Ontario’s pandemic is not well controlled with over 12,000 active case in Ontario with a prevalence of 668.5 cases/100,000 population (click here)

There have been 99,372 cases in Ontario since the pandemic began. There were 1210 new cases today, up +1.2% from yesterday (click here). There have been 6803 hospitalizations, and 3443 deaths in Ontario, since the pandemic began (up 6.8% and 3.5% since yesterday, respectively). The rate of positive SARS-CoV-2 tests in Ontario remains high at 4.1% today. The second wave of COVID-19 exceeds that seen in wave 1 (see graph below).

graph of Ontario's 2nd wave of covid

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 (668.5 /100,000 population) has doubled in the past month and is now 6X higher than in KFL&A (108.1 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 (1100.4 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 760.9 cases/100,000 population (click here). 

graph of hospitalized patients and those in ICU

Deaths and hospitalizations are increasing in wave 2 -on right (See graph above). There are 526 (black line) hospitalized people out of 12,628 active cases (red bars), a hospitalization rate of 4.1% (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).

chart graph of cases, active, resolved and deaths

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).

skyline of Toronto with CN tower

Toronto remains a collection of neighbourhoods with vastly different COVID-19 realities due to differences in social/economic, racial and health circumstances. Although COVID-19 is increasing in the city as a whole, case load is very high in some Toronto neighbourhoods. For example, Weston has had 3707 cases/100,000 residents, roughly 12X the burden of COVID-19 in the more affluent Beachesneighbourhood (297 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 22 cases/100,000 residents, in Palmerstown-Little Italy versus 1088 cases/100,000 residents, in Maple Leaf. 

5) COVID-19 volumes have increased in KFL&A but we remain in the green zone (click here): There have been 18 new cases in the region since my note on Monday. The total number of cases since the pandemic began is now 232. Currently there are 31 active cases locally, down 2 from 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.

Active cases in KFL&A by date as of Nov19th 2020

graph showing active cases by date

6) Canada’s second wave of COVID-19: Over 300,000 total cases and a rapid spike in infection in western Canada: We have had 313,531 cases of COVID-19 in Canada and 11,248 deaths (see below) since the pandemic began. There are 51,083 active cases in Canada today, up over 430 from yesterday. Most cases of COVID-19 in Canada have been (in descending order), in Quebec, Ontario, Alberta and BC. 16.36% of all cases are now active cases. Canada has done over 11.7 million tests and has a cumulative test rate positivity (since the pandemic began) of 2.57%. The sex distribution of the disease in Canada is approximately equal. The hospitalization data is shown in the panel in the bottom right of the Figure below. Ontario remains the province with the highest amount of testing (see bar graph top left below) and has a cumulative positive test rate of 1.71%, although it is much higher lately (4.1%). Note the hot spots on the map, 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.

map of Canada and graphs highlighting covid-19 data for the country

7) The COVID-19 global pandemic exceeds 1.3 million deaths and over 56 million cases (up 2 million from Thursday) (click here): There are now 56,561,918 cases globally and there have been 1,354,780 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 11,573,758 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 19th-below). 

wold map and ranking of countries with highest covid-19

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 but unchanged from Monday) (click here). Positive rates of testing are just over 11.9% in Illinois, 8.8% in Florida, and 7.5% in New Jersey.

Consequently, the US-Canadian border will remain closed for routine travel at least until the end of November (click here).

signs at the Canada USA border

Regular reminders

KHSC bed capacity: Resuming elective admissions but beds remain in short supply

Kingston General Hospital (KGH) has 96 beds available, up from Monday (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! 

animated photo of sunshine and rays in a hay field

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.

screenshot of mobile pre screening app for khsc

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.

photo showing nasal covid 19 swab in nosethree young boys dressed up like doctors

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 2115 deaths in nursing homes (up 34 cases from Monday) 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.

two young school boys in a classroom

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 2147 up from 1913 cases on Monday and more than double the number from 3 weeks ago (985 cases). 

young female toddler holding an apple

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. 353 toddler age children have now been infected to date, up from 322 on Thursday and 209 cases 3 weeks ago.

Stay well!

 

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