COVID-19 update. Holding the line.

As anticipated, Kingston has seen a blip in COVID-19 cases in the past month. Students returning to post secondary facilities, people traveling outside our district or visiting from other communities, the arrival of cooler weather and more indoor activity, and a generally younger demographic acquiring and sharing the virus all triggered that predictable rise in cases.

Our little wave seems to have peaked – for now at any rate. This might be luck but I like to think it is the result of people within our Health Unit generally being responsible and taking care for themselves and our community. Congratulations and thank you for that.

As of this afternoon we have only five known active cases in our district of over 200,000 people.  This is very good news and generally indicates that the virus is under reasonable control in our environs.  It’s not the same for some other areas in Ontario including the GTA, Ottawa and even Hamilton where one “fitness studio” has been thought to have been a source for over 74 cases.

Other areas of Canada and around the world are struggling to contain this second wave.  Italy, France, and the UK, for example, are all experiencing case numbers that greatly exceed the peaks in March. Fortunately, because of improvements in management and the high number of cases in less vulnerable, younger adults, death rates have not shown the same peaks (although they are rising). The U.S. seems not to have ever escaped their first wave. This week their new case numbers are rivalling the highs seen in July.

Australia, after seeing very low numbers for months, had a dramatic surge in Melbourne in late July resulting in daily new cases of over 700. They took determined action to reduce spread, including shutting down that district. Today their new case rate for the country was 8.

So, you see, it is possible to keep a lid on this virus but it requires discipline and following the recommendations from our Public Health authorities. These recommendations might vary from district to district depending on the numbers of new cases, whether there is evidence of community spread (ie not from travel outside the district or as a direct close contact of a known case) and whether our health care/hospital resources are being stretched.  As far as I can determine, despite our recent Kingston wave, no patients were hospitalized.  Since the beginning of the pandemic in March, we have had no cases acquired in our health unit that have required ventilation.

Let’s work on keeping it that way. How can we do that?  It’s pretty simple, really. 

Wear a mask/face covering when indoors with others in stores, theatres, churches, or any closed space – or even outdoors when social distancing is not possible. Wash hands often.

Keep our social interactions limited to a few close friends and family who we know are also being careful. Avoid indoor gatherings of several people when social distancing will be difficult to maintain.

Avoid traveling outside our community or having friends or family from elsewhere come to visit. 

Stay home if we are ill and, if we have symptoms that we think might be COVID-related, get tested and isolate until the test proves negative.

Download the COVID app so we can be notified if we have unwittingly stood beside someone at the grocery store for a few minutes and they have subsequently tested positive.

Get a flu shot. They are now available. I’ve had mine. It won’t prevent COVID-19 but will lessen the circulation of influenza viruses.

We will have to follow these recommendations for the next several months.  But eventually this will subside. We are all experiencing COVID fatigue but these inconveniences far outweigh the perils of  increased community spread or the necessary economic lockdown that would be precipitated by increasing prevalence.  If we are able to keep new cases low, our Health Unit will be able to trace and quarantine patients early. This, too, will limit the spread in the community.

I continue to feel encouraged that management of severely ill COVID-19 patients will continue to improve and that more effective medical management will reduce deaths.  A vaccine will be on the horizon soon although it will take a while to dispense it. We may be thwarted from quickly reaching herd immunity by people who decline immunization but eventually those of us who do accept vaccination will help lower the prevalence of virus within our community and this will benefit everyone. 

There will soon be a rapid test for the virus and saliva tests will become more common than the usual nasopharyngeal swab.  The increased number of testing sites, including in two local pharmacies opened this week for asymptomatic clients, will make it more convenient to be assessed and hopefully lead to earlier detection and isolation of infected  people.

We are in a much better place now than we were in March and we have been really fortunate in the KLFA Health Unit to have been less affected than many districts in Canada or worldwide.  

Can we hold the line?   I hope so. Stay the course.

COVID-19 update. Back to school. It’s time.

COVID -19 will be a threat we have to deal with for the next several months and possibly years. So we need to find a way to reduce its impact on our physical and mental health and our society as a whole.

Part of that transition involves cautiously opening up the economy and getting kids back to school. This makes us all anxious because our generation has not been in this precarious position before. We find ourselves faced with a threatening new virus – a global pandemic. The whole world is wading through a quagmire where there is no sure footing.

I have children who are teachers, grandchildren who are pupils, family who are health care providers and I have been back to working as a physician and teacher of Medical Residents for the past three months both in a clinic and in a small group at Queens. I get it. I understand the angst about going back to work and school. Where I am working we are not doing things the way they were done before but we have been able to find a balance between providing service and taking care not to spark COVID-19 transmission. It has meant several adjustments, wearing a mask for several hours at a time, keeping a reasonable distance between people where possible and respecting others. It has not proved to be that hard to do. Schools will have a similar transition period filled with uncertainty and change and angst but I hope that, with time and inevitable adjustments, teachers and students will find a safe balance point.

There will be pockets of COVID-19 that spring up menacingly in localized schools, neighbourhoods and cities. We are in a much better place now to deal with those clusters than we were this spring. What we have learned about transmission and mitigation strategies may be able to help contain outbreaks and avoid a generalized surge that would require a more widespread shutdown.

Our Public Health authorities are preparing for these inevitable challenges, armed with better testing, improved availability of health care resources and ever increasing knowledge about the virus itself. We now know how to more effectively contain it and have improved management for patients who become severely ill. I have pointed out before that our Canadian numbers seem to be hovering for the past several weeks at a daily new case level of around 500 people per day. Despite this, our reported death rates are staying very low, averaging 4 per day over the past week. In May we were averaging around 150 COVID-19 related deaths per day in Canada! Let’s not lose sight of this good news. Are you aware that, by comparison, on average every day in Canada 11 women die as a consequence of breast cancer and around 12 people die of opioid overdoses? The Canadian Government reports that “Every hour, about 12 Canadian adults age 20 and over with diagnosed heart disease die.”

Now, this is not to downplay the consequences of the current COVID-19 pandemic in any way and other long-term consequences of having had a COVID-19 infection have not yet been determined with any certainty. We are being bombarded, however, with daily statistics about COVID-19 but we are not updated every day on how many Canadians (228 on average) have died in the previous 24 hours of cancer. COVID-19 is scary, but we have been made more frightened by the daily global focus on its statistics. Can we govern our behaviour based on responsible common sense rather than fear?

What do I think should happen now?

Cautious reopening of schools and offices is important to reestablish whatever normalcy we can find in this new pandemic situation. Children need to play and learn with and from each other. Following whatever public health guidelines are advised is important. Masks and social distancing as much as practical and minimizing opportunity for spread within a school cohort will be challenging but we won’t know until we work with it and make the necessary adjustments as time goes on and as we learn more.

What will I personally do In the next few months?

I will continue to work. I will follow the restrictions and Public Health guidelines that will, no doubt, change from time to time, particularly if there is some increase in COVID-19 in our community. I trust the judgement and advice of our local Public Health Unit and know that whatever recommendations they put in place are based on the best epidemiological and medical information available and done with the safety of our community in mind.

Consequences. We are all responsible for our behaviour.
Photos from Kingston Whig Standard and Queen’s Journal.

I was glad to see that the beach at the Gord Downie Pier was closed off entirely this weekend after a couple of days when young adults swarmed to the beach area and appeared not to be taking the required precautions. I hope that our city officials and public health can keep an eye on any elements in our community that are not respecting the current recommendations and move to enforce these with authority. If we don’t follow the rules, we will lose privileges. This applies to restaurants and businesses and movie theatre and schools and churches. And beaches

I will avoid crowded indoor environments. If I find myself somewhere that I think the required precautions are not being respected I will leave, and if I feel it is a significant infraction, I will report it to Public Health.

I will wear my face covering in any situation where I am exposed to people outside my close social circle where I am not able to adequately distance myself. This includes all indoor spots like cafés or stores or offices but I will also put my mask on outdoors if I find myself in the midst of a number of people. And, by the way, the mask doesn’t work if you wear it below your nose.

I have installed the COVID app on my phone and hope that you do too. This will ensure that if I have been in close enough contact to establish Bluetooth connection with another phone and that person, who may have been standing in line behind me waiting for the bank machine for 10 minutes tests positive and subsequently enters a confidential code, I will be notified that I should watch for symptoms and maybe get tested as it appears that I have been close to a person who has COVID-19. This will only work if lots of people do it. It will help in Public Health tracing for community transmission. Do it, please.

I will stick to myself if I am sick in any way. If my symptoms include cough, shortness of breath or fever, I will get a COVID-19 test. This will become simpler over the next months when rapid tests that only require a saliva sample are approved and become widely available.

I will keep a small circle of social contacts who I trust are also being cautious. We have been enjoying outdoor summer patios and walks but as the weather closes in, this will become more difficult. Indoor dining at restaurants poses a higher risk of transmission and if there is any increase in community cases of COVID-19, I will stick to meals at home. I will try to help the food hospitality industry by ordering take out or home delivery. It is not the food that is a risk, but groups of people sitting around indoors for a period of time, all without masks as they eat and chat.

I will not go to bars or indoor parties.

I will not travel outside my community for a while, apart from occasional visits to kids and grandkids in Whitby.

I will be eager to get my annual flu shot and whenever safe COVID-19 immunization is available I will take it.

I will be respectful of people who have views who are not the same as mine (like anti-vaxxers and people who balk at wearing masks ) but that doesn’t mean I have to mingle with them. I have clear boundaries about what I will tolerate or how I will protect myself and others and will adhere to them.

I remain guardedly optimistic that we will pull through this unprecedented disruptive time with lots of inconveniences but hopefully with minimal serious illness or loss of life and manageable strain on our Health Care System. It requires cooperation and diligence from all ages and segments of our community. We are certainly in a much better position in September to manage the challenge than we were when this was all brand new in March. Stay the course. We will get there.

John A Geddes MSc MD CCFP. Kingston, Canada.

This is an op-ed. It is my opinion. Yours may differ. What we know about COVID 19 is changing every day and depends on the current situation in your district. We need to be flexible and adjust to new reliable scientific data.

COVID-19. Facing uncertainty.

If there is one word that I would use to describe 2020 it is uncertainty. There are lots of others but uncertainty in so many ways has been at the forefront.  When COVID-19 first emerged in the early part of the year we had no idea where it would lead.  Just another flu?  Contained in some far away countries? A plague that will wipe us all out?  

In March, we understood little about the virus – it was “novel” after all – and so there were many fears around that unknown part.  Could we get it from packages dropped off by the Amazon delivery man?  Would we need to wash our groceries? Will COVID-19 overwhelm our Health Care System?  Will the measures we put in place to isolate and reduce spread actually work?

Now, by mid-August we have settled into a new reality.  Standing on those little circles, wearing a mask and dealing with a cashier who is behind a plastic barrier has become the norm.  There is less fear about the risk of spread from inanimate objects.  Being able to interact with people outdoors has been a great boon.  Our Health Care System was not deluged and is back to functioning, albeit with some new COVID-19 modifications. It is prepared and well positioned to deal with any new increase in cases should a second wave happen in the fall. The virus, we now know, is primarily droplet spread so hand-washing, keeping a suitable distance from others and wearing a mask when closer approximation is inevitable should pretty much keep us and our community safe. 

Kingston has done remarkably well apart from the nail salon outbreak that was quickly contained. From what we are able to determine our community was COVID-free for over three of weeks until two new cases, both in their 20’s, were found on August 19.  Over 2500 tests have been done in our health unit in the last seven days with a 0.1% positivity rate. This has given us a chance to enjoy more social interactions outdoors with low chance of being infected. 

Many European countries, often using strict social distancing regulations, were able to bring their epidemics under control. They subsequently re-opened their economies, schools and tourist industry. Many are recently seeing upsurges in new case rates. Even Austria (and Australia, too), for some time held as a great example of success at suppressing the virus has had an upswing in cases.  Good news is that, despite this uptick, death rates have not seen the same shift – yet.  This reflects that we now have a better understanding of how to manage serious cases, more knowledge about  transmission, and more diligence around protecting long-term care facilities and vulnerable people. We are seeing a lower rate of infection in older people who are at more risk of serious outcomes. Maybe they are being more cautious than people in their 20’s appear to be. Canadian new case rates have kind of stalled at about 350-500 per day  but our daily death rates for the whole country in the past couple of weeks have ranged from 4 to 10.  This compares to 150-200 daily deaths in early May.   

But, There is always a but, right?

The uncertainty is still there and will likely increase in the next few months as we attempt to get back to “normal”. Cooler weather is approaching which will take us indoors. School for elementary and high school students will resume in September. We can’t keep kids away from school forever and our social and business needs will resume. There has been an obvious increase in tourism in Kingston in the past two weeks.  Downtown patios are full.  People can be seen wandering in clusters many are not wearing masks even when they are in a group.  Restaurants have opened for limited indoor dining.  Students will be returning to Queens and St Lawrence College and we know that this age group have contributed heavily to the Canadian new case figures in the past few weeks and might be less diligent in adhering to Public Health recommendations.  

We will all feel anxious as these new parameters enter the mix.  How can we deal with that anxiety?

Unfortunately, this virus is going to be with us for a while. Maybe forever. We will have to figure out how we best deal with it until effective immunization is available to a large proportion of our population.Even then there will be some folks who refuse to be immunized, lowering the effectiveness for achieving herd immunity. 

There will be new outbreaks. But if they can be contained they will not lead to another shut-down.   We will, no doubt, be inconvenienced and restricted from time to time.  Over the next year, you may be required to isolate for a couple of weeks or your school/classroom/business might have to temporarily close.  The ongoing surveillance, testing and quick responses to new cases by our local Public Health authorities has been impressive and has contributed to keeping our community safe. Ongoing cooperation with our Public Health officers is the essential key to success.  If we continue to identify new cases early and squash opportunities for  transmission, however, we will, as a community, be able to keep functioning.  Advances in management will also lead to a reduction in serious complications of the infection.

The highest risks remain groups of people gathering, particularly indoors, with no social distancing and no facial coverings – especially parties or bar gatherings with clients “speaking moistly” and bending the rules for social distancing. My recommendation is to stay away from these situations and avoid any activities where people are not following Public Health advice.  If you think you are in a situation where  you can not keep the recommended social distancing, indoors or out, wear a facial covering. It will help to protect both you and others.  Continue to wash your hands and keep your cohort of close contacts small.

We have already adjusted to the many changes in the way we interact socially.  Our long term success in coping with COVID-19 will depend on our ability to continue to adapt and to follow the guidelines that our medical experts advise.

John A Geddes MSc MD CCFP

COVID-19 update. Numbers, Numbers, Numbers.

I will start with some good news.  For the first time since late March, Ontario registered less than 100 new cases (76 to be exact) in the past 24 hours. Most of these cases were concentrated in a few districts that have had a particular struggle with the virus but even those regions are showing improvement.  Hospitalizations and COVID-19 deaths are also down across the province.  We shouldn’t get too smug about this, however, as the figures do vary from day to day and can change with very little provocation.  The trend, this week, is in the right direction.

Across Canada there are varied results.  Canadian numbers were generally trending downward until about 10 days ago when a definite uptick occurred.  At the end of June,  Canada’s new daily case rate was averaging  around 300 per day but it has been creeping up with recent averages being near 450.   Alberta and British Columbia, provinces that had been experiencing very low rates and were held as examples, have led the numbers of new cases.  Similarly in countries that had been deemed examples of low infection rates (eg. Australia, Israel, Hong Kong) there have been significant regional outbreaks and increases in both infection rates and deaths resulting in renewed lock-downs.

Canada’s death rates attributed to COVID-19 have remained low despite the increase in new cases.  This likely has several explanations.  The vast majority of early deaths due to COVID-19 were in elderly people with predisposing factors and associated with long term care facilities.  Many of the very vulnerable have succumbed. We are being more attentive and cautious with this population in order to lower their risks. Treatment options for those who are severely ill has also refined and become more effective as we learn more about the virus and what treatments are likely to bring better outcomes. 

Another somewhat worrisome factor is that in new cases the demographics have shifted to involve many more people in the under 40 age group. Although these folks would be less likely to be severely ill or die, it has been suggested that  some of those who have been infected may have undetermined long-term health consequences .  Minimally symptomatic young folks might also serve as a reservoir for the virus in the community and be a source of spread to people who are more vulnerable.

In the last month there have been ten new cases diagnosed in our KFLA Health unit.  Eight of those cases are reportedly people in their 20’s or younger.   Some are known contacts of other cases or associated with our previous nail salon outbreak but five are also listed as having travelled outside our region as where they acquired the virus. It is probable that travel was not the only risk since people in this age group are tending not to be so cautious with social distancing or wearing masks.  I often see collections of young adults on the street, not wearing masks and not keeping the proscribed six-foot distance from each other. Dr Kieran Moore, the KFLA Medical Officer of Health, continues to provide updates to the community. His most recent can be found here or at the end of this post.

Currently we have only 3 active cases, all in isolation, in Kingston.  This means our risk at the moment of acquiring infection in the community is low.  But it is not zero.  I worry that we will get complacent and lower our guard.

I wonder what will happen at the end of the month when college and university students from outside our area return to Kingston. Queen’s may be very diligent about contact on campus but many of these students will be living in houses together and I can imagine that house parties, known to be one of the main ways of transmission in North America in this young adult group, will happen. How can this be managed to avoid breaking our (so-far) very successful Kingston bubble? 

Bars will also be open and as cooler weather follows, so will the tendency to move indoors from the well-ventilated patios we are now enjoying.  Add other respiratory viruses to the mix and we may be in for a difficult fall and winter season.   Will elementary and secondary schools also be open and will it be practical or successful to be able to maintain distancing and lower risk of transmission in these indoor clusters? What happens when the border with the U.S.A. opens up? We will be entering a tricky new phase with more services open and activities moving indoors as fall approaches. 

We are going to have to continue to be diligent, or even more diligent than we are being now, when the cooler weather comes.  We must limit the number of people in any indoor space so we can keep physically distanced.  We will need to become accustomed to wearing a mask when gathering indoors, on public transport and even in some situations outside. It really is not that difficult. Like wearing a seat-belt in the car or a helmet on a bicycle, face masks will become second nature. Even if face coverings only make a small difference to transmission, that effect might end up being a significant help to protect our community.

It is encouraging to know that there are around 150 vaccines being developed around the world and five of them are either in 3rd stage trials or about to start.  This is the final step before approval but it will take a few months to reach the next stage.  Even when vaccines are approved (probably by the end of the year) it will take some time to have them produced, distributed and administered so it will be well into 2021 before we will be seeing an effect from vaccine-induced immunity. But it will come.

 Until that time, we are stuck with doing our best to curtail spread within our community.  We will have peaks and troughs of COVID-19 outbreaks happening sporadically in different geographical pockets.  In some cases this may lead to renewed  local shut-downs and travel restrictions. We have no choice. We must come to the realization that we need to keep disciplined and follow Public Health recommendations if we are to mitigate the effects this COVID-19 pandemic on our Health Care System, our economy and our families. It will end. But not before a few more months of responsible community effort.

COVID-19 update. Whew!

We were doing so well, Kingston! For several weeks in May and June the Kingston, Frontenac, Lennox, and Addington (KFLA) Health Unit district, serving over 200,000 people had only two cases of COVID-19 , both having entered the community from the GTA.  In late June, however, we all squirmed as we collectively felt the equivalent of fingernails on a chalkboard.  A series of cases that started in a nail salon were reported. This led to a significant increase in numbers for our area.  Our COVID-19 case total, plateaued at 63, quickly rose to 105. Thankfully this figure has held steady with no new cases in our district reported in the past week. The one patient requiring hospitalization has been discharged. The outbreak appears to have been squashed.

The surge we experienced was discouraging but not at all unexpected.  We can anticipate that pockets of COVID-19 will break out over the next few months.

This applies internationally, as well as locally.  Australia and Israel, for example, both looked like they had reduced their COVID load to minimal for a few weeks but recently they have experienced increased numbers that have made them backtrack with their re-opening strategies.

In Kingston’s nail salon outbreak, the cluster was rapidly investigated by our local Public Health officials. Testing was ramped up and  contact tracing aggressively pursued.  Our Public Health Unit, led by our MOH Dr Kieran Moore, was ready and acted quickly.  From the outset this leadership in our community with response to COVID-19 has been instrumental in keeping our city and environs as safe as possible.  Dr Moore has also been updating the community with regular You-tube videos that can be found here.

Kingstonians turned out in droves to get tested and over 7000 tests were done over a couple of weeks.  A few hundred people with probable exposure were advised to self-isolate. In addition to aggressive testing and tracing of contacts, the Health Unit quickly implemented a mandatory face-covering policy in indoor stores, restaurants and gatherings.  Other communities across Ontario have subsequently followed suit.   

Management of COVID-19 has also been successful lately in the rest of Ontario and across Canada with case numbers hovering at a manageable level and COVID-19 death rates dropping significantly.  We all watch in horror, however, as COVID-19 spirals out of control in many parts of the United States. In the past week, Canada’s daily new case reports have averaged 290 and daily reported COVID deaths averaged 12. In the United States, with a population about 8 times that of Canada the corresponding numbers are an astonishing 58,000  for daily new cases (hitting 70,000 yesterday) and 650 for daily deaths.  The US deaths are expected to rise in the next couple of weeks since deaths follow the diagnoses by two to three weeks on average.  

These differences in numbers are not just a result of increased testing.   For example, in our KFLA district, the testing rate per 100,000 population has exceeded 13,000 with a positivity rate of 0.4% (4 per 1000).  In the US, the test rates despite being touted as more than anywhere in the world are lower than ours at 12,000 per 100,000 but their positivity rates average 9% (90 per 1000) with a recent high of 19% in the state of Florida.

What can we learn from all this?

Canada, Ontario, and particularly our Kingston district have done a good job of mitigating the consequences of COVID-19 so far.  We had an initial manageable surge as predicted but our numbers have dropped and are plateauing.  We can ascribe this success to a disciplined, coordinated, non-partisan, science-based approach by our governments and Public Health officials.  All Canadians also need to take credit for a concerted attempt to follow the guidelines set out by our leaders. In general our habits have changed to protect ourselves and our communities and our efforts have paid off.

It would be nice if this would just go away all together.  But it won’t. At least, not soon.

We are going to see clusters of COVID-19 outbreaks occur in neighbourhoods, communities and provinces over the next several months.  If we are able to keep these numbers low, we can continue to contain the spread through testing, self-isolation and contact tracing.   Scattered communities may intermittently need to be more aggressive with local restrictions varying from time to time according to diagnosed cases or pockets of infection. 

There will still be some uncertainty when schools open to some extent in the fall.  Cooler weather will have us more indoors where spread happens much more readily than outside.  More university and college students, who have been hunkered down with their parents in home communities will return to Kingston. Eventually the border between the USA and Canada will reopen for non-essential travel.  Canadians overwhelmingly hope this will not occur until the USA has their house in order with regard to COVID-19.   All of these factors bring some uncertainty to what will happen with regard to COVID-19 in the months ahead.

Management  strategies to treat severe cases are improving every week.  If we can keep the strain on our Health Care system as it is currently, we can manage until effective immunization or a specific treatment or prevention  is found.  Effective medical advances will certainly happen but realistically we will be in this limbo period for several more months. 

The rapid containment of our recent local cluster is encouraging and reassuring. We have shown that if we  follow the requests and recommendations of our Public Health and political leaders we can feel confident that we can bring new outbreaks in our community under control and avoid the distressing situation we see south of our border.

It is not that hard to act responsibly.  Wear a face covering where indicated.  Wash your hands.  Avoid prolonged indoor contact with others, particularly in groups.  Keep social distancing where possible. Stay vigilant and guard against complacency or impatience. Hopefully, with competent guidance and cooperation within our community we can continue to keep ahead of any new outbreaks. Stay safe.

John A Geddes MSc MD CCFP July 10, 2020

COVID-19. A wake-up call.

Today I am thinking about that meme of Jack Nicholson in The Shining with “I’m Back” written on it.

After a few weeks of no new cases of COVID-19 in Kingston, with the exception of two cases that had a link to the GTA, the KFLA Health unit has reported 10 new cases in the past week.  Apparently none of them have known connections outside our district.  One of these is associated with a unit at the hospital, another works at a local restaurant and several associated with a nail salon**.  Public Health officials will be working hard to track down, test, and isolate any known contacts. By the time you read this, there may be more.

In the KFLA district, we’ve been both lucky and responsible so far. This recent little outbreak in Kingston should act as a wake-up call to all of us that we are not done with COVID-19 despite our relatively light exposure over the past few weeks.  Maybe the fact that we have had so little in our community has seduced us to be more negligent about following the advised recommendations.

In recent days, I have seen groups of people clustering, not within 2 metres of each other and not wearing masks outside an ice-cream shop, on the street, and in the barber shop.  I have had friends say “It’s OK to get together as long as it is less than 10 people”, seemingly unaware that this comes with the additional caveat that small groups can gather but only if they are following the distancing guidelines.  I see lots of people in stores, even clerks, not wearing a mask. It is encouraging to see the numbers in Ontario and Canada abating. However, we only need to look at what is happening in parts of the US where the guidelines are being resisted to see how quickly this virus can gain control. 

There has also been a shift in the demographic of COVID-19 cases to include more younger people. Perhaps this is because they are more likely to be mingling with each other and they might feel a bit less vulnerable than their older fellows.  I worry about when students will inevitably return to Kingston for university or college and we have all heard of tourists being spotted in Kingston from other districts.  Protecting ourselves by being cloistered is simply not going to be an option. 

I fear that complacency is asking for trouble.  While we are able to be outdoors, our risks are certainly reduced but because of our luck and success at avoiding a major outbreak so far in Kingston we have become lax with following the guidelines.  

I admit to having relaxed in some respects, too.  But I am going to try to tighten up.

I have a small group of friends that I will continue to walk with (less than 5) and we will do our best to keep our distance as much as possible and only meet outdoors.  I have only been in 3 houses of other people in the past 14 weeks and have only had two others come into mine on limited occasions. I will continue to limit indoor visits anywhere.  I will wear a mask whenever I am inside a store of any kind and often on the street when I see that distancing is going to be tricky because of narrow sidewalks or busier pedestrian traffic. I am aware that this will offer me limited protection but any advantage is better than none. It will also act to protect others from me if I am infected and don’t know it. If more of us wear masks under these circumstances it will become the norm, rather than the exception. This will help our community to limit spread. I will wear a mask in a car if anyone else is in the vehicle and insist that they do as well.  I will continue to wash my hands whenever I return from being out anywhere. If I become sick at all, I will avoid others and will consider getting a COVID-19 test if symptoms are suggestive of that in any way.  Testing is easily available now to anyone  and widespread testing with appropriate contact tracing will help to squash any outbreak we have.

It is discouraging to have to admit that this COVID-19 thing is going to be a challenge for several months to come. Like you, I was hoping it would  just go away. But it is here for a while. We need to continue to be diligent, without being antisocial or paranoid, in order to keep it under control, to protect our community and our Health Care System and to limit the adverse effects of this virus to as much as we can.

Stay calm but stay the course. Protect yourself and your community by continuing to act responsibly.

John A Geddes MSc MD CCFP June 25, 2020.

** In the six hours since I posted this blog i have heard that most of the new cases in Kingston are connected to the nail salon. Amazing how one breach in security can have unfortunate ripple effects through the whole community.

Covid-19. Modifying the “Stay At Home” message.

Kingston has remained fortunate that the COVID-19 virus has not caught hold here as it has in some other Canadian communities.  Canada’s numbers have plateaued but not dropped significantly in the past week.  Ontario’s numbers actually went up a bit last week but today’s count is better. The GTA is the biggest contributor to new Ontario cases. The numbers do bounce around somewhat so looking at the trend (and deaths) gives a better sense of what is happening than daily counts. Canadians have been able to keep the demand on our Health Care facilities manageable and that was the initial aim of all the restrictions requested of us. But there is still risk of clusters of spread and we’ve seen that some folks are being somewhat defiant.

In Kingston, our only new COVID case in the past four weeks has been someone who reportedly went to the Greater Toronto Area and brought it back.   I don’t know the exact details but this does point out that Kingston’s greatest risk at the moment is introduction of the virus from people outside our district that we invite in (tourists, relatives) or Kingstonians who travel, don’t adequately physically distance themselves, and then bring COVID-19 home with them.   Initially we were asked to STAY HOME, meaning indoors and not going outside for anything other than groceries or something deemed urgent.  Most of us complied.  It worked.   Now the message is still STAY HOME but the definition of “HOME” could be expanded to be within our district.  The stats from the KFLA Health Unit for the past month would suggest that picking up COVID-19 in our district from people who have stayed inside our community is negligible.

Reported cases of COVID-19 in the KFLA Health Unit as of May 26. The last reported case was introduced from outside our district.

That is great news. Let’s not get complacent, however.  You don’t know who the interloper might be.

We have adjusted to a new social normal already.  In general, people are seeming to keep their distance in public places. No one is offended if you veer away from them on the sidewalk.   Most people walking together are courteous enough to move to single file to let others pass within a safe distance when the pathway is narrow.   I thought today how, in the past few weeks, I have said hello to many more strangers than I did in the past and I’ve been greeted with smiles and responses.

We will adjust to the changes required to keep us safe.  I remember, as a child, bouncing around in the back seat of my parents’ car without a seatbelt and how much of an unwelcome restriction it was to have to wear one. Do you recall how restauranteurs and bar owners thought that a no-smoking policy would ruin their business? Think about the changes in airport security that we accept now as normal when virtually none existed only a few years ago. 

If you can adjust to standing by your German Shepherd as it takes a dump by the fire hydrant, then bend over to scoop up the poop in a plastic bag that you carry nonchalantly on the rest of your walk, you can certainly adjust to putting on a mask when you go into a grocery store. 

There will be other societal changes to which we will acclimatize.  Cash will disappear.  That trend has already started in many countries but these events will accelerate that movement.  For some time, indoor gatherings like theatre or conferences or church will be discouraged.  And people will be reluctant to participate, even if they were to occur.   Limits to the number of people in a store will be common place.  Take out meals will be more comfortable than indoor dining for a while.  There will be sanitation changes required to public washrooms.  Travel will be cumbersome and awkward.  

We will adjust. We have done so to many other societal changes in the past.

Eventually this virus will run its course or become manageable with medical treatment and immunization. In the meantime, we must remain cautious but not scared, compliant with the recommendations made by our Public Health Unit, friendly from a distance and courteous and respectful of others.  As a community we can support each other and protect each other.  We already have, in fact.   Let’s keep that up, Kingston.

COVID-19 We’re just beginning

Let’s start with the good news first.

Kingstonians can continue to breathe a collective sigh of relief as we enter this holiday weekend, knowing that there has been no new COVID-19 case identified in our Health Unit cohort for over two weeks.  All 61 of the previously identified cases have been declared “resolved”.    This is reason for appropriate celebration and considerable relief that we have passed a first wave of COVID-19 without experiencing the feared, overwhelming situations like those we have seen in some other centres around the world.

In addition the KFLA Health Unit figures indicate that only 18% of the cases in our district were “Community Acquired”, the rest being found in returning travellers or direct contacts of known cases.  Our Health Unit serves about 215,000 people. That means that of the 61 diagnosed cases – I say “diagnosed” because we don’t know if there are others out there that we have missed because they were not tested – 11 of them arose from sources unknown or random community transmission. That is one such case in 20,000 people.  Those are not bad odds.

Does this mean we can let down our guard?  NO, indeed!

It means that the measures that have been put in place in our community have minimized the spread of the virus and it has had nowhere to go so it has temporarily petered out.  But it is still there.  And it is still there with a vengeance in Montreal, only 250 kilometres away.  The reality is that our community remains highly vulnerable because we are still quite COVID-naive. So far, we Kingstonians are living in a bit of a bubble.

I wonder what will happen when we open up a bit or when people go to their cottage near Ottawa or when they visit their family in Toronto and return to Kingston.  What will happen if we start to get people from Montreal coming for a summer weekend vacation?  Or when some college or university students return to Kingston in September?  If we become overly confident and let our guard down too much will we start to see more community spread of this virus that is still out there, waiting to find  an entry point?

The World Health Organization this week has suggested that we are in for a long haul with COVID-19. Like HIV, it may be a pathogen that we will have to accept is here to stay.   We will eventually develop some “herd immunity” that lowers its prevalence but it may always be there, lurking and threatening to surge if given the chance.  There are also studies this week from both Spain and France suggesting that in these countries, where there has been a significant burden from disease this spring, only about 5% of the general population has antibodies. A similar study done in Boston and reported today discovered about 10% of the population had antibodies.  This suggests that the prevalence of undiagnosed infection or sub-clinical infection is less than we had hoped for and that significant proportions of the population are still vulnerable to infection.

This week, the Canadian government approved an antibody test that will be very helpful in identifying what is happening in our various communities to track this infection and aid in management. It is not ready for widespread clinical use yet but this is a start.

Just like what has happened with malaria, and TB and influenza and HIV, I am confident that we will eventually come to learn much more about this novel coronavirus and develop strategies and medical managements that will lessen the impact or be able to treat it.    We will develop better/quicker screening and testing for COVID-19 and be able to earlier identify and quarantine those with an active infection and their contacts. Maybe there will be a drug that can be taken by contacts that will suppress the infection proactively.  Hopefully, we will come up with immunization that will help to improve the herd immunity.  It will take a while to provide immunization to 7 billion people. Unfortunately, there will likely be a backlash and resistance from those who oppose vaccinations of any kind that will slow the process for the rest of us.

In the meantime we need to stick to what we have found is actually protecting us so far. Wash those hands often. Limit your close exposure to others.  Don’t gather in groups where distancing is not practical and particularly in indoor closed areas. Work from home when you can. Consider wearing a mask when you are shopping or in a situation where physical distancing is impractical.  When you are sick, stay home. Better yet, get medical advice and possibly a COVID test if it is advised so your recent contacts can be warned if you are infected and so you don’t spread it unwittingly to others.  We will need to take particular care of those in Long Term Care facilities and, as a community, protect individuals whose co-morbidities put them at increased risk of serious consequences of the infection.

Although the last 9 weeks have felt like a lifetime, we are only just starting. The COVID-19 virus is new to the world. We are guessing to a certain extent, using scientific reasoning, how best to mitigate its effects at the moment but how this unfolds over the next couple of  years is taking us down an unknown path. International cooperation and learning from the experience in other parts of the world has been helpful.

Some folks are eager and others might be understandably anxious about re-opening the economy. The bottom line is that we can’t remain in total isolation forever. My opinion is that if we proceed gradually in a responsible way and remain ready and responsive to deal with any emerging infection clusters that develop, we can go ahead with caution. It will be slower than we want and there will be challenges to working around new restrictions that will be in place for some time. We will adjust.

Life will change. Our societal habits will change.  But humans are pretty resilient and flexible and we have science and technology that was not there for past pandemics on our side.  Our short-term success shows that we can do it.  It’s a long course ahead, however, and we will have to buckle down and accept that sobering reality.

John A Geddes MSc MD CCFP

Here is a message from our Local Medical Officer of Health posted today on the KFLA website.

COVID-19 Now what?

If epidemiologists and Public Health specialists are right, Canada has just about reached the peak – or at least a plateau – on the COVID-19 curve.  How long we stay at the peak before coasting down the other side is uncertain. New cases are still being reported in large numbers but they have tended to level out rather than increase exponentially.   A significant number of deaths are also still occurring, especially associated with Long Term Care facilities, but these, too, are anticipated to start to decline in the next couple of weeks.  

When I wrote about this in mid-March, the fear was that we would be overwhelmed with a surge in COVID-19 infections that would inundate our Health Care Facilities and hospitals with patients requiring intensive care. We were cautioned that we must “flatten the curve” and with Public Health guidance, we significantly changed our social interaction with others and washed our hands until they are raw. This strategy seems to have worked as hoped.

We must bear in mind, however, that we are flattening the curve, not eliminating it all together. Yet. The downward curve will be very gradual and prolonged.  COVID will linger for quite some time and there will always be the threat that if we lighten up our precautions too quickly the curve will bump up where we don’t want it to be.

In Kingston, Ontario, where I live, we have been especially fortunate to have avoided the anticipated huge peaks and potential overwhelming surge on our Health Care facilities. The KFLA Health Unit, serving a population of about 215,000, reports today that there have been a total of 59 confirmed cases with 56 of them already declared “resolved”. Our health unit has recorded no COVID-19 deaths. No COVID-19 patients are currently in our ICU or on a ventilator.  In the last three weeks there have been only four newly-confirmed cases. Thanks to both good luck and preemptive precautions taken by our local Public Health Unit, our Long Term Care facilities have, so far, remained safe with no outbreaks. This is indeed a great relief for our community. You can see for yourself in the image at the end of this post, how our local curve has remained flat for several days.

This good news does come with a bit of a snag, however. Because our community has been so spared of a significant outbreak, it means that most of us are COVID-19-susceptible.  The challenge becomes how we can start to relax our restrictions but not find ourselves at square one again because very little has actually changed about our community in terms of COVID-19 vulnerability.  As long as we remain somewhat cloistered as a community, our risks of infection are lower than many other areas that have been more heavily infected.  But how long can we remain isolated as people start to travel a bit more widely to visit family or students return to Kingston or folks take a bit of a vacation in the summer outside our area?

The Ontario government has published a scheme whereby things might gradually open up but the timing of reducing restrictions will be entirely dependent on what is happening in terms of infection rates, hospitalizations and deaths.  Realistically, it will take a long, long, time to return to any semblance of normal.  And the normal that we return to will inevitably be different from our past. The physical distancing thing will certainly remain a standard for some time.  It will affect the way we shop, interact with friends, travel and celebrate together.  Group activities will be curtailed for months to come. 

There is still a lot that we don’t know about this virus.  We will need more widespread NP swab testing to identify the presence of virus.  When we test more broadly, we will be able to identify earlier the people who might be infected and thereby infectious to others. If we quarantine those people and actively contact trace to find anyone who might have had interaction with them and then test and isolate those people, we will reduce exposure to others within the community.  We know that there is a significant number of people who exhibit no symptoms and yet are infected and able to spread the virus.  We need to be more aggressive with testing to identify as many as we can so the transmission to others is reduced. 

Eventually antibody testing to determine the presence of both recently and more remotely acquired antibodies that hopefully will result in immunity will give us a better sense of how widespread asymptomatic or mildly symptomatic infections have been.

I anticipate that some medical management will soon be determined to be available to those who are more acutely ill.  This would really help to manage the severely ill and reduce the strain on hospital resources.  We have not found this treatment yet but I am certain that eventually we will discover an effective management strategy.

The ultimate fix that will allow us to return to “normal” will be if and when an effective, safe vaccine is developed and made widely available to people throughout the world. We know that vaccination works. Consider, for example, what immunization has done to squash Smallpox, Polio, Tetanus, Measles. Getting it right is important, however, so that we know that it is safe and effective.  Combined with antibody testing, this might be the ultimate “Get out of jail free” card we await.

I have spoken to a lot of people who are wondering if the cough and fever that they had  in January was actually COVID-19.  Although we know that this COVID-19 virus was probably circulating, undetected, weeks before it was first identified in labs, it is probably more likely that most of those folks with “flu” early in the year were suffering from another viral illness. Acute Respiratory Infections caused by a number of agents  give similar clinical pictures.  The only way to find out how many of those January coughs were COVID-19 will be when the antibody test is available for widespread use. 

In the mid 1980’s when HIV was ravaging various segments of our society and decimating African communities, we talked about ‘safe’ sex. Eventually we realized that no sex was 100% safe so we changed the terminology to ‘safer’ sex.   I think we will need to think similarly about COVID-19.  Until a large percentage of the entire world has developed  immunity, this virus will be present and we will have to do what we can to minimize our own risks and limit spread in our community. It won’t be perfect, but with careful hand washing, limited close contacts, changes to the way that we gather in groups,  physical distancing where practical, testing, contact tracing and eventual immunization, we will be able to cautiously inch forward to arrive at a new normal.  The world has encountered plagues and epidemics and pandemics before and survived.  We will too.  But it will take a long time to get there and many things will have changed irrevocably in the meantime. 

John A. Geddes MSc MD CCFP

COVID-19 update. Kingston has dodged the bullet for now. But are we dealing with a revolver or a machine gun?

When I first wrote about COVID-19 a couple of weeks ago it was on the horizon but had not arrived with any intensity. The major concern at that time was that the virus would surge in and overwhelm our Health Care System.  Canada has had an advantage over countries that had been bombed by this infection already in that we could see it coming and take action to avoid it.   Social distancing was advised early.  Public Health measures  and planning were put in place.

In Kingston, Ontario, where I live, we have been fortunate to have been able to keep the “curve” pretty flat.  Our community of about 215,000 people has only had 53 documented cases of COVID-19 with 36 of those people having recovered.  As of April 10 we have not had any COVID-related deaths and only two people are currently in hospital being treated for COVID-19 specifically.   Some of this is just good luck.  But the community has certainly embraced the principles of social distancing responsibly.  Other factors that may have helped are that the local university and college has closed up and many students have gone home.  We have no tourists. Clinics are treating their patients “virtually” rather than in face-to-face visits.  We have passed the 14 day risk period from returning spring break or winter snowbird travellers who have isolated themselves to protect the rest of us.  Congratulations Kingston, it’s working for you right now.

There has been a partial flattening in other parts of Canada, too, but we are yet to reach the predicted peak later this week.  Deaths from COVID will rise across Canada for the next couple of weeks. There is a 2-3 week lag between the number of new cases and the number of deaths because deaths don’t occur immediately when the diagnosis is made.  

Is there a story behind these numbers that we have to consider?   How reliable are these statistics?   How do they compare to other countries or communities?

We have to bear in mind that the numbers are only for confirmed cases of the infection.   People who have had milder symptoms or even no symptoms at all are not included in these figures.  This means that the rate of infection in the community is certainly much greater than the numbers presented and that we must continue our social distancing practices  both to protect ourselves and to protect others.  

How can we actually compare how we are doing?  Hospitalizations and deaths are figures that are more reliable and a reflection of what is happening in the community in general.  About 10% of those who are infected will require additional medical care and are more apt to be tested and identified. We can look at those cases to determine the overall prevalence in the community.   Death rates attributed to COVID-19 are also an indicator of how widespread the illness is. The consensus is now that COVID had about a 1% death rate.  This does vary from one demographic or population to another but the affect of the virus on the community can be ascertained by looking at the death rate figures.  Because population numbers from one country to another vary,  I have been watching the deaths per million population number to get a sense of how comparisons can be made.    

According to the Worldometer statistics up to April 10, Canada currently has had an attributed  COVID death per million of our population of 15.  For the USA this is 57 deaths per million.  For Italy it is a terrible 312.  Italy’s high rate is in part because they were taken by surprise when the infection arrived and their health care system was submerged quickly.  This means that many people who might have benefited from more intensive care were unable to get it and subsequently died. There may be other factors like population density, a higher older population and more families with multiple generations living in the same household that influenced this as well. This disastrous result is particularly what we have been trying to avoid by “flattening the curve” and Canada has had the advantage of a bit of time to prepare and take precautions earlier than Italy.

We also have to be aware that this pandemic, although global, tends to be presenting unevenly in scattered epidemic areas, like New York City or Milan or even Toronto for example.  So numbers might be drastically different from one locale to another. 

The down side of being in the lower numbers right now is that this curve has not been erased but is only being flattened – stretched out so to speak.  Because we have a lower prevalence in Kingston, we remain more vulnerable as we don’t have a significant proportion of people with naturally acquired immunity and immunization is yet a year away at least.   The question is how will this unfold over the upcoming months?  If we let up on our social distancing will it lead to a surge later that is hard to deal with?  How can we gradually return to a more normal society and when will that happen? Will children be back in school in June? In September?  When will people who have been  laid off get back to work? How long will we be asked not to go for coffee or dinner with friends or family?  When will I be able to go to a movie or a theatre event?  When will travel restrictions be loosened up?  

No one has answers to any of these questions yet.  For the time being those of us who live in Kingston need to be glad that we have dodged this bullet and that we are currently able to sustain a reliably functioning health care system and not be overwhelmed with unmanageable numbers of seriously ill COVID patients or COVID deaths.  But we are stuck in this holding pattern for the near future and maybe several more weeks or even months.

 Before it is all over we will, unfortunately, lose many lives to this infection.  But with time, it will subside. More people will acquire natural immunity from infections that don’t present severely.  We will get more intensive testing to identify and aggressively trace and isolate specific people with symptoms and their close contacts. We could even identify those who have no symptoms but are infectious in order to limit contagion.  We will get a quick test to identify people who are immune.  I hope that we will also get some medical management to help manage the more severely ill patients, possibly reducing the need for intensive care and ventilation.   And the final success will come when we eventually have immunization.  

In the meantime, we must stay the course because for now, it is working, Kingston.

If  you want more numbers, here are some figures from Worldometer and the KLFA Public Health Unit as of the end of yesterday, April 10, 2020. These figures change by the hour.

John A Geddes MSc MD CCFP

Kingston, Canada