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 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.

COVID-19 Update. How this extrovert deals with Social Distancing

We are social beings.  We all need connection. Some of us more than others. This Social Distancing thing is urgently important so we can minimize the anticipated surge in cases of COVID-19 in our communities in the next few weeks.  Unfortunately, the need to socially distance ourselves is not going to go away soon. 

Social distancing is not the same as quarantine or self isolation.  Those measures apply to people who are returning to Canada from international destinations, people who are  symptomatic and awaiting COVID-19 test results, those who have had a COVID-19 diagnosis confirmed and people who have had direct contact with COVID-19 positive cases.  These folks should not mingle at all with others for 14 days or until they are deemed cured.

Of course, if you are sick you should stay home, even if it is not COVID but is another Acute Respiratory Infection. This will minimize spread but also not lead to so many others getting a cold and then worrying it is COVID-19

All the rest of us need to practice Social Distancing. This means we minimize as much as possible close contact with others as well as follow all the other the routine advice for hand washing, elbow-sneezing, avoiding hugging or handshaking and not collecting in clusters of people.

I will share with you some practical strategies that I am adopting so I can comply with the need for social distancing over the next several weeks.

First of all, I will, at this point, go for walks outside.   I need to get outdoors and have some exercise. We are lucky that spring is around the corner so we can actually get some fresh air.  BUT that comes with the caveat that we must keep our distance from others.  The advised two metres is best.  I have a couple of friends who are also following the rules with whom I will meet periodically so we can smile at each other, have a bit of a laugh together and share some conversation.   But we will work to maintain the required physical distance as best we can. 

When I am out I don’t touch anything that I don’t need to touch.  I don’t sit on a public bench, for example.  I carry a small microfibre cloth in my pocket so if I have to open doors or carry a basket in the grocery store, I can use the cloth to make the contact.  When I get home I throw it in the wash. (I have a pack of 5 that I got at Dollarama).   If I can open a door using my elbow or hip or a push button or Key fob I do that rather than touch the handle.  I am also putting my clothes in the laundry basket if I have been out somewhere during the day so I can start with fresh clean clothes every morning. Although the virus has been shown to live on plastic and metal for up to 72 hours, it can also remain viable on clothing or cardboard for a day or so. Better safe than sorry.

When I pass someone on the street I am attempting to say Hello or Good Morning even if they are strangers.  It is always pleasant to be greeted and a brief verbal hello might just make someone’s day.

I will try to go to stock up on groceries at off-peak hours.  I live only 10 minutes from my usual grocery outlet so I will walk there early in the morning or go in the last hour before closing to avoid the busiest times.  We are being assured that generally the food supply will not be affected.  The empty shelves that you may have experienced last week are the result of exceptional panicked buying and hoarding. It will take a while for those folks to use all that toilet paper they have in their garage so that will leave some for the rest of us when we need to buy it.  Same with meat and pasta and rice and flour and…    There will be food.  Don’t panic.  And while I am at it, I will extend our thanks to the people who are working to keep us supplied  – clerks, shelf stockers, truck drivers, all of you.  We need you and appreciate this service.

I will still see my family who don’t live with me from time to time.  We will avoid hugging or touching and we will be careful to wash our hands or anything that we might have touched.  We will keep our distance as much as practical.  If any of us are sick at all we will self-isolate and not expose the others. 

For example, I spent a couple of hours this morning with my 8-year-old granddaughter. Kids are scared. They know what is going on and they also know that their family and friends are scared too.  We were able to have a great visit, taking extra care to avoid close contact, washing our hands after handling anything and playing interactive games that we streamed to the TV.   We talked about COVID, how to look after ourselves and our worries. When she went home, we both felt infinitely better.  She was happy and so was I.

I have been making a point of connecting with others both locally and internationally by using FaceTime or Messenger or Skype for audio/video chats.  We need to stay connected.  Text messaging is fine when we are busy and have the opportunity to interact face to face easily but a smile or the sound of someone’s voice does a lot to sooth that need for connection.

The economy is also taking a hit right now and where that leads is uncertain for all of us.  We have enough to worry about now without being fussed about things we can not control.  None of us know what the next month or six months or year will bring.  It is futile to try to plan that far ahead right now so I am refusing to spend my energy trying to plan that far in advance or think about what situation I or, for that matter, the world, might be in by then.  It is best to set priorities about what we need to do now.  Currently my priority is to be responsible to my community, my friends and family and to myself so as to dodge as much as possible the immediate effects of COVID-19. Catastrophizing (is that a word?) is counter-productive and I will try to avoid going that route in my head.

There have been an absolutely phenomenal number of individuals, entertainers and groups that have reached out online to help us stay upbeat and mentally busy in our distancing mode. I have looked for those and will definitely join in to pass the added alone time.  I will also break out a jig-saw puzzle soon.

This will pass.  Unfortunately, the need to socially distance ourselves and the drastic disruption to our normal routine is going to last for weeks or even months. It will definitely get tiresome and I am afraid that it will be too easy to put these thoughts aside and let our guard down when the sun is shining and the weather is encouraging.  In order for it to work, however, we will need to stay the course. Remember that it will take some time before we reap the benefits of this challenging change in our social interactions.  

Hang in. Help others. Support each other. 

John A Geddes MSc MD CCFP

Kingston, Canada

March 20, 2020

My favourite coffee haunt looks more like a bowling alley these days. Up to be a pin-boy instead of a barista, Nick?

Addendum: Six hours after I loaded this post, Balzac’s closed (along with other coffee shops like Starbucks.

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

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.

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.