COVID-19 Numbers, numbers, numbers

Posted on April 3, 2020 by johnageddes

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.

My Covid-19 update. ‘Social Distancing’ is imperative at this point.

Posted on March 13, 2020 by johnageddes

Consider this. Three weeks ago, on February 22, 2020, there were 11 known cases of COVID-19 in Italy. Since then, there have been over 15,000 diagnosed cases and 1000 deaths in Italy alone that have resulted from this viral infection. Italy now has a COVID-19 case rate of 250 per million population. The country has an excellent health care system but it has been overwhelmed. One might expect that the death rate is going to go up more because many seriously ill people will not now be able to get the intensive care they need. There are just not enough resources to cope with the rapid spread of the virus. The country is shut down and suffering badly both medically and economically.

Today, in Canada, with a population half that of Italy we have 122 known cases, a rate of 3.2 per million. This changes by the hour. Where will that be three weeks from today? We need to do whatever we can, and do it now, in order to mitigate the effects of this infection in our communities.

In Canada, we have a couple of advantages. Italy has a slightly older proportion of people over 65, those who are at highest risk for serious consequences of COVID-19 (22%) compared to Canada (17%). Their population of 60 million, nearly twice that of Canada’s, lives in a much smaller geographic area and therefore are living closer together in general. Most importantly, North Americans have had some advance warning of what COVID-19 can do, how it is spread, and what measures can best be taken to control it. Hopefully we can take what we have been able to learn from this head start in China, other places in the Far East and Europe and quickly – very quickly – change our behaviour in order to lessen the eventual impact this virus will have on our communities in Canada.

We have heard the “wash your hands”, “cover your nose when you sneeze” and “stay home when you are ill” messages and I suspect most of us are complying with those suggestions.

Another significant factor that has reduced the rate of spread of this disease and has been proven to be effective, both in the past and in some countries that have instituted it seriously for COVID-19 is Social Distancing. The reason this works is because COVID-19 is spread by droplets, not by fine little viruses floating around in the air. When an infected person sneezes or coughs, the droplet spray from their mouth or nose can travel a few feet but not more. If we are in the way, we are vulnerable. It may also land around them and live for some time (there are varying estimates how long and I am not going to spread inaccurate information to you). If you pick up the virus with your hands touching the sprayed-upon item you might then transfer the virus to your face and nose and become infected. Hence the hand washing advice.

So, increasing our comfortable social distance and minimizing close contact of numbers of people in close approximation to us is imperative. This is why in the last 24 hours we have learned that all schools in Ontario will be closed for two of weeks after next week’s March break, that the NBA and NHL have suspended the rest of its season (Netflix night in Canada replacing Hockey Night?), and that the Kingston Canadian Film Festival made the difficult decision to cancel the remainder of the festival after only one day. We all need to be supportive of this strategy, both for our own benefit and that of our community.

In the next while we will all be significantly inconvenienced by school closures, lack of availability of some items at the stores from people hoarding, cancellation of entertainment events and sports competitions and we will all have our anxiety piqued by the general sense of panic around us. Younger people may realize that their risk of death from this is much less than older people but it is not zero. They must also adhere to our community restrictions for the benefit of their neighbours and friends and parents and to avoid over-taxing our health care system which is already running at near capacity. If we can “flatten the curve” of this illness we can deal with it If it comes in a surge we are going to be overwhelmed.

I am 72 and hate to be called “elderly” but, in this case definition, I qualify. People over 70 have a 10% or more chance of becoming seriously ill with this virus or dying from it. Seniors with health problems like heart or lung diseases are at even greater risk. They should pay even more heed to the social distancing message.

So, what is my advice?

If you are sick, stay home. Don’t go to the Emergency Department. You might call your Family Doctor’s office for advice and to know if you need to be seen. There is no treatment for this illness at present so resting, taking medication to lower fever and drinking fluids is all that you can do. If you are becoming increasingly ill, you need to talk to your family doctor’s office about where to present for assessment and treatment. There will be designated regional assessment centres and you should not show up at the wrong place where you might contaminate other vulnerable people.

Wash your hands whenever you come in from being out somewhere or use hand sanitizer if you can find it available.

Cover your nose and mouth when you cough or sneeze.

Be ready to be in isolation for 14 days if you become infected. Develop a circle of friends or relatives who can support each other by bringing groceries and leave them on your doorstep if you are in isolation. It is probably reasonable to have some extra pasta or soup or cereal in your larder but hoarding should not be necessary and even makes things worse for others. In Italy, where most of the country is currently shut down (including tourist sites, restaurants, cafes, churches) the grocery stores and pharmacies have remained open.

When you do go out, think about keeping a reasonable distance (at least a metre) from others. Don’t shake hands or hug when you meet a friend or colleague. The old elbow bump would be more appropriate (if you have not just sneezed on our sleeve, of course.)

If you are over 70, you might want to limit your exposure by staying away from group events, exercise classes, theatres, festivals and even church if you can not keep a metre between you and your neighbour. The more you are exposed in a group, the more chance you have of being infected. Even people who are in the incubation phase with no symptoms can shed virus and be infectious for a couple of days before they realize they are sick.

Help each other. We are all in this together. We need to be cooperative, to listen to our Public Health Leaders and to follow instruction. This is a time to think about our community, manage our health care resources and support our family and neighbours. The measures i have talked about have been proven effective. But only if we follow them.

Although i am a pretty fearless traveller, I have decided that, until this has all stabilized in some way, I will stay in Canada where I can access my health care, not have to worry about international travel restrictions or being quarantined in some other country. There will, no doubt, be good travel deals to be had while the tourist industry is struggling but I prefer the safety and security of home for the time being.

Our municipal, provincial and federal governments, led by public health experts, are evaluating the best course to be taken to reduce the stress of this outbreak on our communities in terms of health and economics. There is no right answer. This is unproven ground and you can see that the situation changes daily. I think we need to be patient and trust that our community leaders are assessing and making decisions that are in our best interest and I am glad that they will guide us through this turbulent time.

I was astounded when my previous blog article was shared and read by over 40,000 people in three days. I thought I was writing it for 50 of my Facebook friends who were asking me questions. https://johnageddes.com/2020/03/08/coronavirus-in-kingston-canada-my-take-on-what-we-might-expect/

I soon realized that there is a thirst out there for some common sense advice from a regular Family Doctor and so I hope that this is helpful as an update for a crisis that seems to change by the hour. I have had lots of questions in the comment section of my previous article and am willing to answer any that I feel qualified to answer if you post it in the comments. I am not claiming to be an “expert” but I try to be a rational, down-to-earth family physician who has tried to keep up on the medical writings about this serious and unique health crisis. I hope these suggestions are helpful to you in wading through this quagmire of information about COVID-19.

John A Geddes MSc MD CCFP

Kingston, Canada

March 13, 2020

Check out this article about how social distancing (or lack of it) was shown to have an effect on spread of influenza in the 1918 epidemic in the US.

Coronavirus in Kingston, Canada. My take on what we might expect.

Posted on March 8, 2020 by johnageddes

There has been a lot written and published about COVID-19 and I don’t want to add to the barrage of information out there. But I thought I could give my friends some indication of what I have learned and what to expect with regard to current status about COVID-19 as it pertains to our Kingston, Canada community.

In some ways, we are lucky that we are farther down the chain. Our Public Health authorities have had the advantage of seeing how this is playing out in other parts of the world and how the virus is behaving so appropriate measures can be taken to limit its effect here.

The numbers around the world change by the hour. For up to date numbers you can see how many people have been diagnosed worldwide and in every country (and their outcome) on this website. https://www.worldometers.info/coronavirus/

This novel coronavirus was unknown only a few weeks ago and currently there are over 100,000 cases and there have been 3600 deaths. Using these figures, gives a death rate of over 3%. The death rate from influenza which causes thousands of deaths a year is 0.1%. In other words, according to current worldwide figures, COVID-19 has about 30 times the death rate of influenza. This figure may be a bit high as there are likely undetected cases in the community which would skew the denominator but even conservative estimates indicate that COVID-19 is at least 10 times as deadly as influenza which causes about 3,500 deaths in Canada and over 50,000 deaths in the USA annually.

Of those who contract the virus, 80% will have relatively mild symptoms – cough, fever and shortness of breath – that will resolve in a few days with symptomatic treatment. Another 10% may develop pneumonia (viral or a superimposed bacterial pneumonia) and require additional support. Another 10% may require hospitalization and 3% will die of complications of the infection.

Currently the highest death rate occurs in people over the age of 70 and particularly those with other chronic diseases like diabetes, COPD, cardiovascular disease and high blood pressure. If you are under 50 and in good health your risk of dying from this virus is minimal but you might have a couple of weeks when you are sick. You will, no doubt, know people who become seriously ill and who die from this virus.

As for your kids and grandkids, for some reason, not yet understood, children either tend not to get this virus or are not significantly affected by it. It may be, however, that children can present a minimally ill or asymptomatic reservoir that can spread the virus to others who are more vulnerable.

The virus attacks and replicates in the lungs primarily and as lung cells are compromised, breathing becomes more difficult. Any illness associated with significant fever also causes malaise, muscle aches, headaches and fatigue.

The virus spreads by droplets from sneeze or cough. Droplets containing virus can also be on hands, phones, desks, coins or any other surface. If you are within a metre or so of people who sneeze or cough without covering their face, or if you handle some object that has been contaminated by infected hands or droplets from sneezes and then touch your face, you may become infected,

The incubation period from exposure until when symptoms appear is about 5-7 days. Most people who have been exposed and will get ill, should show signs of the illness by 14 days.

The test for the virus is a Nasopharyngeal swab. This is done by advancing a swab through your nostril to the back of your throat for a sample. It is uncomfortable but not painful. Currently there there are an adequate number of swabs to test and identify patients who are most likely to be infected and the turnaround time for a test, done in Kingston, is 24 hours. If you require a test, you will be asked to self-isolate until the results are back.

The 95% of people who acquire this virus and recover from it will likely develop immunity, at least for a few years. Only time will determine with certainty how we respond with acquired immunity to this virus but one hopes that it will be like how we react to similar viruses.

There is no immunization yet for this virus and it will take at least a year to get one. longer to have it widely distributed. Having an influenza shot is a good idea if you have not yet done it BUT the FLU shot does not protect from COVID-19 (just as it is not effective for the common cold).

There is no current treatment, other than symptomatic management for the disease in the 80% who are mildly affected. These folks should NOT go to the Emergency Department or even to their doctor’s office. They should self-isolate at home for 14 days, use fluids, and acetaminophen or ibuprofen. Cover their mouth when sneezing or coughing. Avoid close contact with others in the household. Do not go to the store or out to places where you are in contact with others. You might wear a mask to avoid droplet spread to others but masks are now in short supply so you may not be able to get them. Masks in public to prevent getting the disease are not effective and not necessary.

People who are more significantly ill with an Acute Respiratory Illness (ARI) of cough, fever and shortness of breath should call their doctor’s office for information as to where to be evaluated. In all likelihood, there will be Regional Assessment Centres set up in our community where all people with ARI will be evaluated and tested if deemed necessary. This will avoid anyone with COVID-19 passing the virus on to other people who are seeing their doctor for other reasons and may be more at risk for serious complications. Currently the testing in Kingston will likely be for anyone presenting with an ARI and who have been outside Canada in the previous 14 days since person to person spread in our community has not been happening – yet. Yes, this means if you were in Florida for Spring Break and within 14 days develop a cough or fever, you will be sent to the Regional Assessment Centre and be tested. Drive-through testing might also occur. You wind down the window of your car and are swabbed through the open window, thus avoiding contamination of others in an office or waiting room.

Even those who are not ill or are minimally affected should be prepared to be significantly inconvenienced by an outbreak which will inevitably arrive in our community. There may be school closures and cancellations of sporting events or conferences or meetings. Certain travel might be curtailed. Theatres or any place where people may be congregating within a metre of each other may be closed. You may be required to self isolate (stay home) if you have been in close contact with a known COVID-19 case or if you have returned from traveling to a high risk area – and these are increasing all the time.

So, if most people have mild illness, what’s the big deal?

This is a totally new virus and none of the 7.7 billion people in the world will have acquired immunity to it. (Except the 60,000 who have had it in the past month and have recovered.) We are all susceptible.

This virus is readily transmitted by droplet spread.

We have no treatment to cure it.

It will be at least a year before immunization is available.

It has a high death rate for vulnerable people.

It will put a huge strain our health care resources if it comes in a big wave.

We can not prevent this virus from hitting our community but we can dampen the spread by diagnosing and isolating positive cases, avoiding close contact with others in group events, avoiding shaking hands or hugging friends or co-workers, washing hands regularly with soap and water or using a 60% alcohol hand sanitizer (currently not available as it has been sold out), and avoiding touching your face.

If you have symptoms or if you have been diagnosed by swab, you MUST self isolate. This may seem like a bother if you are only mildly ill but you need to avoid spreading this into the community and to others who may be at much higher risk.

If we can flatten the curve of infection in the community using the above measures, we will be able to deal with those who are more seriously ill with the virus. If there is a huge spike in cases all at once, the health care system will be overwhelmed, there will not be enough beds to support those who are seriously ill and health care workers will also be affected and need to self isolate which will cut the number of health care providers who can look after the acutely ill.

If you want to see the restrictions ITALY has put in place today, March 8, 2020, to try to curb spread of this virus for the above reasons, check here : https://johnageddes.com/2020/03/08/restrictions-applied-in-italy-on-march-8-to-curb-spread-of-covid-19/

All this is changing day to day. I have tried to give a current status of how we are or might be affected in Kingston. We have to hope that there will be a slow infection rate so our system is not overwhelmed. If we are lucky, there may be some abatement over the summer (we don’t know if that will happen yet but it does with influenza) but, even if that happens, it will definitely be back with a vengeance next fall as immunization will still not be available at that time and there may be more asymptomatic or mild cases throughout the community.

I hope this information is helpful to you. We will be OK in the long run but there may be some bumps along the way. Be glad that you live in Canada where we have a capable, publicly-funded health care system.

John A Geddes MSc MD CCFP

March 8, 2020

I have published and updated to this information HERE on March 12, 2020.