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

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

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

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

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

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

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

What do I think should happen now?

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

What will I personally do In the next few months?

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

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

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

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

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

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

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

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

I will not go to bars or indoor parties.

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

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

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

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

John A Geddes MSc MD CCFP. Kingston, Canada.

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

COVID-19 update. Numbers, Numbers, Numbers.

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

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

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

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

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

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

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

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

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

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

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

COVID-19 update. Whew!

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

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

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

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

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

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

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

What can we learn from all this?

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

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

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

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

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

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

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

John A Geddes MSc MD CCFP July 10, 2020

COVID-19 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.