prevention | johnageddes

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.

Kingston Ontario’s history includes a cholera epidemic that, between 1932 and 1934, killed ten percent of the city’s population. Kingston residents are all familiar with the downtown McBurney Park ( known locally as Skeleton Park}, now home to an annual summer arts festival, where many of the victims of this epidemic were buried 180 years ago. Kingston’s popular home-town band, The Tragically Hip, even have a song that references the outbreak. The Hip Museum website has a great summary of the cholera epidemic that basically closed down all the stores in town with the exception of lumber outlets to make coffins.

Cholera was then, and remains now, a serious consequence of inadequate sanitation and clean water. It was not until John Snow traced an outbreak in London to a water pump on Broad Street that we understood that the disease was spread through water exposed to fecal contamination from other infected people.

In Canada today, 99 percent of the population has access to improved sanitation and clean water. Cholera is a disease of the past. But for communities in developing world countries, including those in East Africa, where, by comparison, only 60 percent of people have access to improved sanitation, it remains a serious threat.

Just last week I received an email from Dr. Karen Yeates, a Kingston nephrologist who is currently with her family in Tanzania. She writes:
“I just managed a cholera epidemic over Christmas at the little hospital I am doing some part time consulting at. I never thought I would see it in my lifetime as a physician…..its incredible that we have the ability to do everything we can in this world with technology and medicine but, the poor and disadvantaged in sub-Saharan Africa struggle with diseases of more than a century ago. We have had over 30 cases but no deaths thankfully. We traced it to lack of toilets and clean water in the three communities where it came from. They had stopped boiling water due to lack of ability to afford wood for their fires…its a choice of make food or boiling water but not enough wood for both. Inflation is high here right now due to the strong US dollar and everything has become more expensive for families here.
I was thinking about CAN-ASSIST and how many toilets you have built over the years….we can’t forget about these simple things…..:).

Keep doing what you all do so well. “

The CanAssist African Relief Trust continues to work to improve water and sanitation for schools and communities in East Africa. This week we are starting a latrine project at a school on Ukerewe Island in Lake Victoria. In 2015 we installed clean water supply and toilets in ten different schools, clinics or lakeside villages.

There is little specific treatment for Cholera other than aggressive fluid and electrolyte replacement. Prevention through sanitation, protection of water supplies and hand-washing remains the key. This YouTube video is in Swahili and aimed at instructing African people about the importance of these prevention measures. It is simply presented and without knowing a word of the language it is easy to understand the message.