September 14, 2020 - 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

| 14 September 2020

Today’s Headlines

To fix the LTC problem we cannot incarcerate seniors.
Vaccine trial resumed in the United Kingdom
Ontario has first day with over 300 new cases today
We are opening a satellite COVID-19 testing centre at Queen’s at Mitchell Hall tonight which will test 50 students/night.

To fix the LTC problem we cannot incarcerate seniors. The epicentre for COVID-19 mortality remains our long term care facilities (LTC) (click here). The ~78,000 residents of Ontario’s LTC facilities account for less than 0.5% of the population but they still account for ~67% of all deaths from COVID-19! There have been 1848 deaths to date. The mortality rate has dramatically declined in the past month. There have only been 3 deaths in Ontario’s LTCs in the past month (and none since my last report September 10th).

However, as the pandemic drags on these people suffer a uniquely painful and unfair fate. They have been in lockdown for ¾ of a year. Residents of LTC facilities have been functionally incarcerated, not allowed to come and go and until quite recently not allowed to have visitors. The motivation for these restrictions was to protect them and the intensity of the lockdown was no doubt made worse by the initial failure of the LTCs to protect the residents. However, a lockdown is the wrong solution. It has become painfully clear that LTC residents need access to family not just for emotional reasons; but also for the pragmatic reason that family members were providing essential support in our poorly staffed LTC facilities. In the absence of “visitors” care has deteriorated, and with it the physical and mental health of LTC residents. For example in June 2020 it was reported that “More than 230 long-term care facilities in Ontario last year reported either more residents being physically restrained on a daily basis, more potentially inappropriate use of antipsychotic medications, or more residents with pressure ulcers that had gotten worse than reported the same five years ago. (click here).”

screenshot showing senior citizen sitting in wheelchair with mask looking out window

On June 18^th Ontario began a cautious reopening of access allowing visitors to enter LTC facilities once again (click here). Here is a link to the visitation guidelines which were updated effective September 9th, 2020 (click here) Notably the policy indicates that “If the resident is not self-isolating or symptomatic, a maximum of 2 caregivers per resident may visit at a time.” This is a step in the right direction but sadly seniors in LTCs have already paid twice for the pandemic, first we failed to protect them through systemic flaws in our patchwork senior care system (which is not really a “system”). Then in response to our failure and the shocking mortality rates, we locked these facilities down and trapped seniors in isolation, allowing their physical and mental health to deteriorate in ways that have yet to be fully counted. All too often decisions about access and freedom of movement of LTC residents is being left in the hands of local administrators, leading to capricious enforcement of policies, and in some cases these decision makers value 100% freedom from risk of COVID-19 over the residents global well-being. So what is the solution for our LTC residents? We need to create facilities that have only single rooms, ensure proper pay and proper staffing numbers for PSWs (who should only work at a single site), we should provide appropriate access to PPE and to COVID-19 testing. Apart from the creation of single rooms which may take some time all these reforms can happen immediately (and many LTCs are already achieving these goals).

Vaccine update (click here): Astra Zeneca has announced it will resume enrollment in its vaccine trial (see my last note), although it provided no details as to why it was now considered safe to resume this study . Interestingly, enrollment has resumed in the UK but the American arm of the study remains closed. Likewise, Pfizer has announced it is expanding the size of its vaccine clinical trial to include 44,000 subjects, offering little detail as to why this expansion of sample size was needed. While communication with Pharma needs to be more open and transparent, it is good news that the research is progressing. An effective vaccine offers one of the clearest potential solutions to this pandemic.

photo of outside of AstraZeneca building in Britain

Ontario has its first day with over 300 new cases today: After a month or more of rates of new cases of COVID-19 of ~150/day, Ontario has had 200 cases/day for 3 days and today has 313 new cases. These new cases are coming from Peel, Toronto and Ottawa. This increase in case incidence reflects significant community spread. We will need to watch closely to determine whether this is the beginning of a second wave of COVID-19 versus a series of outbreaks. It is still too early to declare a second wave in the COVID-19 pandemic, and nationally numbers remain stable, as will be discussed subsequently. It’s also important to remember that we, as a population, have the power (through our behaviours and compliance with public health policies) to markedly reduce the risk/magnitude of a 2^nd wave of this pandemic.

Local COVID-19 Update KFL&A:

There have been 3 more cases of COVID-19 in our region since my note last Thursday, bringing the total since the pandemic began to 115 cases. Currently there are 3 active cases locally and they are recovering in the community (see update from KFL&A Public Health) (see graph).

chart of information re COVID-19 in KFL&A

COVID-19 in KFLA; 3 active cases recovering in community

We have performed 2058 COVID-19 tests in the past 4 days at KHSC. The positive tests were from the Kawartha area and none from KFL&A. There are no inpatients with COVID-19 in KHSC. We are seeing greatly increased community demand for testing at our assessment centers. Since Sept 1 we have tested 3500 people. The wait time for testing is ~1 hour. We test 300 people/day at the Leon's Centre (170 were symptomatic and 130 were asymptomatic yesterday). Most symptomatic people are children from daycare or school. The demand for these tests related to school children and daycare kids are likely to increase.

The asymptomatic people being tested are mostly Queen’s students who want to be tested to “do the right thing”. We are opening a satellite COVID-19 testing centre at Queen’s at Mitchell Hall tonight which will test 50 students/night. This center is only for symptomatic students or students who are part of contact tracing. This is not favouritism towards Queen’s university students; rather it is an acknowledgement that university-age people are a key demographic for this virus and one which, if not properly managed, can lead to large COVID-19 outbreaks. Thus KHSC is enhancing testing of this at risk population.

Care of the 99%: At KHSC operations are stable, our PPE supply is good and we are making progress in increasing our capacity for elective care for the 99%. We have adequate bed and ventilator capacity to deal with a 2^nd wave of COVID-19 (at least if it resembles the first wave), see Figure below.

However, our outpatient clinic volume remains at only ~50% of what it was pre-COVID-19. We recognize the urgency of increasing our ambulatory patient capacity and are striving to get to ~70% of pre-pandemic capacity, with the balance of clinic visits being provided by virtual care (telehealth and video visits). I am encouraging all physicians in the Department of Medicine to ramp up their in person patient clinic visits to deal with a backlog of disease while our local epidemiology permits us to safely do so. This request is fully aligned with KHSC policy.

Ontario’s COVID-19 epidemic-first day with over 300 cases in a day: (click here) (see map below) Ontario’s COVID-19 prevalence rate is 296.5/100,000 up slightly from a month ago when it was 263.8/100,000, and much higher than in KFL&A, which has a prevalence of 53.6 cases/100,000 population. Toronto has a rate 9 times higher than Kingston (489.9 cases/100,000 population). The region with the highest prevalence of COVID-19 remains Windsor (602.4/100,000), largely because of a poorly regulated agricultural sector and suboptimal housing of farm workers.

map of Ontario showing areas of COVID-19 prevalence

There were 213 new cases of COVID-19 in Ontario yesterday (up 0.5% from the day before) and 313 today. It is concerning that this is the 4th consecutive day with more than 200 cases in Ontario, after a month of new cases accumulation being under 200. There have been a total of 44,068 total cases, 4944 hospitalizations, and 2813 deaths to date (a downward revision of the number of deaths based on updated source documents). The 1.0% rate of positive SARS-CoV-2 tests yesterday (down 0.3% compared with prior day) continues at a stable low rate over the past month, consistent with the first wave of the epidemic being controlled.

SARS-CoV-2 prevalence tracks with social determinants of health: Consider the neighbourhood to neighbourhood heterogeneity in the epidemic in Toronto (click here). Toronto remains a collection of neighbourhoods with vastly different COVID-19 realities due to differences in social/economic, racial and health circumstances. For example, the Beaches has 97 cases of COVID-19/100,000 residents whilst Weston has 1918 cases/100,000 (see map below)! Thus, there is no single “Toronto”, as seen through a COVID-19 lens; it’s a diverse patchwork with a 19-fold variation in disease prevalence.

There has been a recent increase in active cases in Toronto (overall)-see graph below. This graph was last updated last Friday, so does not reflect a weekend with increased new case numbers.

COVID-19 is affecting certain racial groups disproportionally. Note the much lower prevalence of COVID-19 in white people (see graph below) (click here). Although there may be some difference in biological susceptibility based on race/ethnicity it is likely that much of this difference relates to socioeconomic factors. The best way to stop the epidemic in Toronto is to address housing conditions in its poorest neighbourhoods and focus on broader equity and inclusivity initiatives.

graph showing rate of covid-19 cases among ethno racial groups vs all of Toronto

The first wave of Canada’s epidemic is resolving (although there has been an increase in cases in some regions in the past week) We have had 136,659 cases of COVID-19 in Canada and 9171 deaths (see below). Most cases (89%) are resolved. While the situation in Canada remains good, with low levels of hospitalization, low rates of new cases and most cases resolved there is an upward trend in new (active) cases (orange line top graph) in the past week.

graph of case timelines and trends in Ontario

Moreover, some provinces are seeing major increases in new cases (notably BC and Manitoba)-see BC below:

graph of cases timelines and trends in BC

Uptick in active COVID-19 cases in BC-Sept 14th (orange line)

With universities and colleges back in session it is likely there will be further increases in cases. Western University has reported an outbreak with 5 infected students (see below). The first of what will likely be numerous outbreaks in university students (click here).

screenshot of Western University building

Although university age people tend not to suffer severe consequences of COVID-19 (few hospitalizations and virtually no deaths) they do socialize actively and many fail to follow rules for physical distancing so they constitute a potentially important population that could spread the disease. Continuing reminders of the effective nonpharmacologic interventions to prevent disease spread are important for this group, an indeed for all of us. It is important to: stay home if sick, wash hands frequently, mask if in indoor spaces, maintain 6 foot physical separation, avoid large gatherings.

A reminder: we remain as susceptible to this virus as we were last year! There is little immunity amongst Canadians. This reinforces the need to continue to practice physical distancing, hand washing and use of masks when in doors. It does also remind us of the importance of targeted public health interventions.

COVID-19 testing: Ontario SARS-CoV-2 testing continues at a rate that exceeds the national average (which is 17.7%), with 22.8% of Ontarians having been tested to date ( click here). Our positive test rate in Ontario remains low (1.34%).

graph of tests performed in Canada as of Sept 14th

SARS-CoV2 Testing in Canada as of Sept 14^th 2020

In contrast with Canada’s 2.0% rate of positive tests, the USA has an average rate of positive COVID-19 tests of 5%. In Florida the positive test rate remains high at 12.6 %, while Texas has declined to 7.9% and Arizona to 7.4%. Despite an encouraging decrease in the rate of positive tests in the US, down ~ 2-3% over the past month (click here), the US-Canadian border will remain closed for routine travel at least until the end of the month.

graph of rate of positive tests in USA as of Sept 14th

Rate of positive COVID-19 tests in the USA Sept 14^th 2020

The COVID-19 global pandemic: There are now 29,053,724 cases globally and there have been 924,953 deaths. The pandemic hot spots are in the Americas (Brazil, Mexico, Peru, Chile and USA), India and Russia (click here). The USA with 6,521,887 cases alone accounts for 23% of the global pandemic. India now has the second largest number of cases (see list of countries with the most cases below left). The map shows where active cases are located. The right 2 columns show the countries and states with the greatest number of COVID-19 related deaths. The yellow line (bottom right) shows a logarithmic plot of all the cases in the world over time. Globally the case load has not flattened, although the rate of increase is slower than in March.