July | 2020 | johnageddes

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.

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