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

COVID-19 Numbers, numbers, numbers

The COVID-19 numbers out there can be scary.  We have cocooned ourselves for the past several days and the stats are still going up.  Most of us have nothing much else on our minds but anxiety about where this is headed, particularly when we look at the devastation that has happened in Italy, Spain and New York City.   We wonder “Is Ontario next?”

Today the Ontario government released projection figures that are both disturbing and motivating.  We know how this virus tracks from how it has exploded in other parts of the world.  With those models as a predictor, Ontario, without any restrictive measures in place, would have anticipated 300,000 cases and 6000 deaths by the end of April.   If we follow the current recommendations to limit physical contact and stay at home most of the time, however, that number can be reduced to 80,000 cases and 1600 deaths by April 30.  Still an incredible burden but it means we will effect a significant reduction of over 4400 deaths in Ontario this month alone if we just stay the course.  If we restrict further (and further restrictions may ensue) that number could be reduced even more.

It may be frustrating to see that we are trying to stay in and stay apart and the number of cases and deaths in Canada keep going up.  But that was anticipated. For a while we were slow to get testing results so the statistics lagged by a few days.  We also had the influx of travellers returning to Canada and some bringing their virus with them.  Some of those didn’t self isolate as diligently as requested. Although they thought they were not infected or had minimal symptoms, they could have spread the virus to others. There is also a 7-14 day incubation period before the symptoms become evident and some people have minimal symptoms of infection. This means that people who were exposed two weeks ago might just now be showing symptoms and becoming ill enough to test. And others are simply unaware that they are infectious.

Don’t get too frustrated by the current increasing numbers.  From the charts of the various possible trajectories, it is evident that our current social isolation is actually working to reduce the otherwise catastrophic infection and death rate that would have happened if left unabated.

Another graph that was released today was also encouraging. (see below) It shows the possible numbers (in red) if no measures were in place and the anticipated numbers if we are compliant with the current stay at home  and physical distancing recommendations (in blue)   The two dotted lines represent the Ontario capacity for ICU management in the province both in place prior to the pandemic starting (the lower line) and now planned (the upper line).  We are fortunate that we have had time to anticipate this imminent glut of infection cases and our hospitals are putting additional capacity in place.  If we follow the blue curve we will be able to sneak under the expansion capacity line.  That is good news.  

Our COVID-19-associated death rate per million in Canada right now stands at 5 per million population as compared to 21 per million for the USA and 243 per million for Italy.  Remember that deaths occur later in the process so they will continue to rise for the next while. As long as we can stay under that dotted line and have adequate access to ICU beds, we will be better able to manage the seriously ill and more lives will be saved.  Many of the deaths in countries with very high rates were partly as a result of ICU capacity being suddenly overwhelmed and medical management simply not being available.

So, the message is that the potential for seriously devastating numbers is there but we are already going to have some effect on the curve with what we are doing now. With more dedication to these restrictions we can do even better over the next month. This will be a marathon, not a 100 metre dash.  Take some big breaths.  Settle in to our new temporary reality and know that it is making a difference, saving lives, and in the long run things will get better.

Through various medical connections and meetings, I have been impressed that our Public Health officers, Ministry of Health and local and provincial physician groups and clinics have been very actively anticipating and planning for the surge that we anticipate that we will experience in the next couple of weeks. I feel confident that in Kingston, Ontario, and across Canada, we will receive excellent care and support during this unprecedented challenging time.

For my neighbours in Kingston, as of this morning we have 48 confirmed cases and no COVID deaths in the KLF&A district with likely many more out there who are not ill enough to have been tested. General testing has been a bit restricted initially because of the need to ration available tests but this will likely loosen up a bit soon so more cases might be confirmed. This increased testing may lead to more confirmed cases being reported.