March 20, 2020 COVID-19 report

To my colleagues – all and especially those of you in the front-lines of care,

It pains me when I want to say happy weekend, knowing that none of us will have much of a weekend. And yet, please, please, please try at least to catch-up on much needed sleep and enjoying at least for a bit your families, as we are in this for the long haul.   

To keep you well informed, here is RNAO’s daily communication for Friday, March 20 – our third month of the COVID-19 outbreak in Canada – a global pandemic. To see previous updates visit RNAO updates and resources on COVID-19 for members and other health professionals. Feel free to share these updates with other health professionals at home or abroad.

Can health providers returning from travel go back to work immediately? Most of the emails I received today address the discrepancy between what Health Minister Christine Elliott announced earlier this month and what some of our teaching hospitals are doing. Let’s be clear, Minister Elliott announced in no uncertain terms that any health professional who travels abroad MUST upon return to self-isolate for 14 days. RNAO is thanking the minister for a decisive action. Now, RNAO will ensure that our colleagues in the front-lines of this battleground are protected from working side-by-side with colleagues who return from abroad. Although most of the new cases are local transmission, the evidence is clear that travel abroad remains a risk factor. RNAO urges all health professionals – in the strongest possible terms – to defer any non-essential travel during the pandemic. We need you at work and we need you healthy! I attach for you, again, the directive that went to all sectors leaders here. I ask that if you experience interpretation challenges at your workplace, you inform me right away.

As I shared yesterday, new research suggests persons can be infectious even before symptoms appear, or when they have very mild symptoms like those of the common cold. Although these are preliminary studies, they emphasize the role of social distancing even among people who appear “healthy”, since one cannot rule out that a healthy looking person may actually be shedding virus. Several studies support this conclusion, although how important asymptomatic transmission is in the spread of the virus remains unclear. A lead researcher concludes: "Don't forget about hand washing, but at the same time we've got to get people to understand that if you don't want to get infected, you can't be in crowds." He adds: "Social distancing is the most effective tool we have right now." We should also exponentially increase public education of how to practice social distancing. I want to emphasize that education is not only the government’s responsibility, but ours – individually and collectively. 

Today was the second day of the #TogetherWeCanDoIt campaign and the noise is even lauder to #cheer4healthworkers. See here one of the hundreds of tweets that have been posted. Please take a few minutes everyday at 7:30pm to join -- 7:30 p.m. today, and it will continue every evening until we defeat COVIC-19! Please join in whichever way you can – our collective energy can cheer the millions of health providers, social service and other essential front-line workers in Ontario, Canada, and around the world tackling #COVID-19. At 7:30 pm local time, each evening, step out onto your porch, balcony or open a window and make some noise in honour of the heroes working on our behalf. You can bang some pots and pans, you can sing a song, you can applaud, ring your bike’s bell, and yes – you can honk. Watch the short video (courtesy of a CP24 interview yesterday eve) RETWEET and GET READY TO PARTICIPATE. Use the hashtag #TogetherWeCanDoIt and tag @RNAO when sharing how you and your community are cheering!

WHO and Global Citizen launched #TogetherAtHome, a virtual, no-contact concert series to promote physical distancing and action for global health. Chris Martin, lead singer of Coldplay, kicked it off earlier this week with a performance from his home. More Solidarity Sessions are planned to promote health, show support for people who are staying at home to protect themselves and others from COVID-19, and encourage donations to the COVID-19 Solidarity Response Fund.

To increase access to reliable information, WHO has partnered with WhatsApp and Facebook to launch a WHO Health Alert messaging service. This service will provide the latest news and information on COVID-19, including details on symptoms and how people can protect themselves. The Health Alert service is now available in English and will be introduced in other languages next week. To access it, send the word "hi" to the following number on WhatsApp: +41 798 931 892.

MOH EOC Situational Report #55 here – EOC reports that the number of confirmed cases in Canada today is 869, and 12 deaths including two persons in Ontario. EOC reports 50 new cases that bring our province to a total of 308 cases (of which 5 are resolved cases). EOC reports that in Ontario, at this time, we have 5,485 persons under investigation with lab results pending. Several important guidance documents, directives, and memorandums are attached to today’s Situation Report:

•  Primary Care COVID-19 Guidance 2020-03-20 (here)
• EO Notice - ODB Program Changes and Guidance for Dispensers during the COVID-19 Public Health Emergency (here)
• DM OH CMOH memo COVID19 update March 20 2020 (here)
• Collab Table Summary (2020-03-19) (here)

Toronto is also investigating its first reported cases of COVID-19 in a homeless shelter, a long-term care facility — and a paramedic.

Coronavirus COVID-19 Global Cases by Johns Hopkins -- CSSE reports a total of 318 cases in Ontario and 1,085 total cases in Canada as of March 21, at 12: 43 am.   

Public Health Ontario maintains an excellent resource site on materials on COVID-19. This is an essential resource for Ontario health providers; I encourage you to visit it.  Make sure to check the Public Health Ontario technical brief on the Updated IPAC Recommendations for Use of Personal Protective Equipment for Care of Individuals with Suspect or Confirmed COVID-19 (in English and French).

Health Canada's website provides the best information capturing all of Canada. It contains an outbreak update, Canada's response to the virus, travel advice, symptoms and treatment, and resources for health professionals. This is, again, a vital resource for those following the COVID-19 outbreak in Canada.

The Public Health Agency of Canada has developed two new guidance documents for health system partners. The first, regarding community-based measures to mitigate the spread in Canada, and the second on informed decision-making related to mass gatherings.

Situation Report 60 from WHO updates that worldwide there are 234,073 confirmed cases (24,247 new) and 9,480 deaths (1,061 new). There are 41,035 confirmed cases (5,322 new) in Italy, 18,407 confirmed cases (1,046 new) in Iran, and 17,147 confirmed cases in Spain (3,431 new). Other countries to note are France (with 10,877), Germany (with 10,999), US (10,442), Switzerland (with 3,863), UK (with 3,277) and Netherlands (2,460). China has 81,300 cases (with only 126 new, an exceptional achievement), and 8,652 confirmed cases in South Korea (239 new). The number of confirmed cases worldwide has exceeded 230,000. It took over three months to reach the first 100 00 confirmed cases, and only 12 days to reach the next 100 000. It appears the next 100,000 will be reached within 3 days.

You can also find up-to-date global numbers in Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE. These numbers appear to be more updated than those of WHO. For example, while WHO indicates there are 10,442 cases in the United States, CSSE reports 19,624.

WHO announced that the first vaccine trial has begun just 60 days after the genetic sequence of the virus was shared by China. This is an incredible achievement. To ensure clear evidence of which treatments are most effective, WHO and its partners are organizing a large international study, called the Solidarity Trial, in many countries to compare different treatments.

Worth repeating - RNAO Policy Corner: The need to test, trace contacts, and isolate cases

We are going through a very challenging period. Governments in Canada have reacted responsibly and have acted seriously and in coordination to effect social distancing while preparing health-care services for the enormous demands that COVID-19 may be presenting. There is a flurry of activity to prevent infection among vulnerable individuals such as retirement and nursing homes. Hospitals are preparing to receive large numbers of very sick persons requiring intensive care.

At the same time, social distancing is having a profound social and economic impact. Social distancing means for many social isolation, loss of jobs and livelihoods, small businesses closing down, compromised mental health, family violence, children losing education, loss of financial reserves, evictions and homelessness, and many, many other concerns. Governments are moving, and need to move much more aggressively, to lessen some of these negative impacts, particularly the economic ones, so families, particularly those in precarious and low-wage employment, self-employment, vulnerable situations such as Indigenous communities, or the gig economy, can survive while maintaining their dignity, health, housing and ability to care for their children and provide for their families.

Concurrently with lessening the tough effect of social distancing, MUST aggressively do all we can to shorten this period of social distancing. The situation will become dire, at many levels, if this period of social isolation prolongs itself beyond just a few weeks. In the view of RNAO, there is one major tool we are not using sufficiently, at this time, to flatten the virus curve and shorten the period of social isolation: testing and contact tracing.

In the words of World Health Organisation head Tedros Adhanom Ghebreyesus, there has not been an urgent enough escalation in testing, isolation and contact tracing, which should be the "backbone" of the global response. He said it is not possible to "fight a fire blindfolded", and social distancing measures and handwashing will not alone extinguish the epidemic. He says he has “a simple message for all countries: test, test, test.” If we don’t test, then we don’t know who has the virus, and thus one cannot isolate and trace it.

We have been slow to learn this lesson in Canada, perhaps influenced by the terrible example south of the border, a lack of leadership that is driving the United States, according to some observers, to a catastrophic situation such as the one experienced by Italy, but on a much larger scale. That’s why it is good the border has been closed to non-essential travel. 

In Canada, the situation with testing is better, but we should not be complacent. Ontario and British Columbia, the provinces with the highest numbers of cases, have had to set new limits on who will be tested due to a demand for testing materials. In BC, testing is limited to people showing symptoms of the COVID-19 disease who are either hospitalized, work in the health-care system, are residents of long-term care facilities, or are part of an investigation into a cluster or outbreak. A similar situation happens in Ontario. That leaves many potential community cases of COVID-19 undetected, untraced and not isolated. These community cases are the most dangerous ones in terms of propping the epidemic curve up, the opposite of flattening it.

The logic for this approach is faulty. A provincial health authority in BC says: "We have recently adapted the testing strategy in BC. People with mild symptoms who can recover on their own at home don't need testing because the medical care and advice is the same regardless of whether they test positive or not." This approach completely ignores the need to trace contacts of persons who are COVID-19 positive. In fact, this approach assures there will be community spread, since the effort to trace contacts and isolate them has been abandoned.

We should learn the lesson from South Korea. Amid dire global trends, South Korea has emerged as a sign of hope and a model to emulate. The country of 50 million appears to have greatly slowed its epidemic; it is reporting less than 100 cases each day now, down from 900 at its peak at the end of February. It has done so without locking down entire cities or taking some of the other authoritarian measures that helped China bring its epidemic under control. Behind its success so far has been the most expansive and well-organized testing program in the world, combined with extensive efforts to isolate infected people and trace and quarantine their contacts. South Korea has tested more than 270,000 people, which amounts to more than 5200 tests per million inhabitants—more than any other country except tiny Bahrain. In contrast, the United States has so far carried out 74 tests per 1 million inhabitants.

Canada has so far done about 1,400 tests per 1 million, much better than the US, but still only one third of the testing levels reached in South Korea, and very little of the contact tracing and case isolation done extensively in that country. South Korea’s experience shows that “diagnostic capacity at scale is key to epidemic control,” says Raina MacIntyre, an emerging infectious disease scholar at the University of New South Wales, Sydney. “Contact tracing is also very influential in epidemic control, as is case isolation,” she says. This was part of a systematic and coordinated societal effort in South Korea that included a number of crucial elements, according to the WHO. It educated, empowered and engaged communities; it developed an innovative testing strategy and expanded lab capacity; it rationed the use of masks; it did exhaustive contact tracing and testing in selected areas; and it isolated suspected cases in designated facilities rather than hospitals or at home. As a result, cases have been declining for weeks.

RNAO’s policy recommendation: Canada needs to ramp up, within days, its capacity to test. At the same time, the increased testing capacity should be accompanied by aggressive contact tracing and case isolation. Our current approach, relying too much only on social distancing to flatten the curve, will prolong the period of social distancing and the enormous social and economic dislocation. If we want to shorten this period, and diminish the social and economic impact, we must strengthen the weak elements in the current COVID-19 strategy: test extensively, trace aggressively, and make sure contacts are isolated.  

RNAO Policy Corner: COVID-19 and Social Equity

COVID-19 will only be beaten with a massive collective effort, and that should be possible because so much is at stake for everyone. It is easy to forget that the burden of risk and illness falls on the most vulnerable, as it always does. We are aware that older people and those with co-morbidities are very vulnerable to COVID-19. The social gradient also comes into play in a big way with this new pandemic:

• Your ability to self-isolate and protect yourself from viruses plummets as your income falls. Homeless people can't self-isolate.
• Lower income people live in more crowded circumstances and must take public transit.
• Unlike well-paid workers, low-income workers and the precariously employed can't afford to take self-isolation leave, as they are very unlikely to get paid leave (74% high income vs. 14% low income), and they generally don't qualify for unemployment insurance. They have to choose between the certainty of more stress because of increased poverty and the risk of a serious illness.
• Lower income people can't afford to stockpile food and other essentials.
• Lower-income people and the precariously employed also tend to work in sectors adversely hit by closures and falling expenditures -- such as the service sector and particularly in restaurants, hotels and tourism. And the services they provide generally

To avoid raging pandemic hot spots, a key component of an effective government pandemic policy must be the support of economically vulnerable people. If we can't make it possible for them to protect themselves, we are all in big trouble. The federal emergency support announcement this week is a step in the right direction, but much more must be done. See below Support for Vulnerable Populations and Workers.

RNAO’s ACTIONS:

As of today, 4,500 RNs and NPs responded to the RNAO survey with availability to provide virtual clinical care or non-clinical services. We have already deployed 59 to Ottawa Public Health and a good number to other places. RNAO is in the process of working with various other areas of need and will connect with you depending on the locations required. We also understand that TeleHealth will necessitate additional staff. We know that you are ready and eager to help and thank you hugely for it!   

Note to employers in Public Health Units and other call centres: If you are experiencing a staff shortage to answer phone calls following protocols, please let us know. Write to Daniel Lau dlau@rnao.ca and we will connect you within hours with RNs and NPs in your locality. We are here for you!

URGENT STEPS FOR GOVERNMENT TO TAKE: RNAO’s VOICE

Canada needs to ramp up, within days, its capacity to test. At the same time, the increased testing capacity should be accompanied by aggressive contact tracing and case isolation. See our analysis above.

Strict social distancing. Please become a #SocialDistance Champion by educating your families, friends, colleagues and members of your community. #SocialdistancingNOW works to slow down  community transmission in Ontario. Even if the number of people infected by the virus continues to climb, a slowdown in the progression can do a life-and-death difference for the healthcare system. Please also help neighbours who leave alone, exchange phone numbers with others, and help make sure that social distance doesn’t translate into social isolation.

Massive public education and enrollment. RNAO and our members are heavily engaged in mainstream and social media to keep the public fully informed, engaged and enrolled into #socialdistance action. We ask that you follow us at @RNAO and @DorisGrinspun and retweet + facebook as much as you possibly can.

Support for Vulnerable Populations and Workers. COVID-19, and the measures required to address the emergency, have profound social equity impacts (see RNAO Policy Corner above). For example, protecting Ontarians experiencing homelessness and those living in crowded shelters are issues we are actively pursuing with government officials, and we are pressing for an urgent plan. We also know that government is meeting with Indigenous leaders to discuss their preparations for COVID-19, and we are eager to hear the outcome of those discussions. While we were pleased with the initial measures announced earlier this week by Ontario’s Premier Doug Ford to protect workers from losing their jobs as businesses suspend operations or they have to stay home to take care of children, RNAO was also urging for much more to be done to assist low-wage earners and those in precarious employment, who may transmit disease simply because they have no option. Thus, we are pleased with the announcements made this week by the federal government, but much more needs to be done. Workers and businesses hurt by the COVID-19 pandemic may be eligible for part of the $82 billion aid package announced by Prime Minister Justin Trudeau, which includes $27 billion in direct support for those struggling to find work or care for family members. The package, now before Parliament, stands to adjust the rules on who qualifies for employment insurance (EI), and includes two emergency benefits for those who don't.

Please continue to keep in touch and share questions and/or challenges of any kind, and especially shortages of PPE. Send these to me at dgrinspun@rnao.ca. We are responding daily and are continuously solving your challenges. WE ARE HERE FOR YOU! You can also use the health provider hotline and website regarding questions about the outbreak, protocols, preparedness, and more. The toll free number is 1-866-212-2272, and the health provider website, updated regularly with useful resources, can be accessed here. An important reminder that the health provider website and the toll free number are for you – as a health professional – and not for members of the general public.

Ontario’s ministry’s public website on the COVID-19 exists to inform the general public – encourage your family and friends to access this public website. The WHO has provided an excellent link for you to share with members of the public here. RNAO has updated its information page for the public. Please share it widely.

Let’s remember our colleagues in the front lines in Ontario, Canada and in other countries. These are tough and stressful times, and also the time to be together and support one another.

Colleagues, together, we are and will continue to tackle COVID-19 with the best tools at hand: accurate information, calmness, determination and swift actions! 

Doris Grinspun, RN,MSN, PhD, LLD(hon), Dr(hc), FAAN, O.ONT
Chief Executive Officer, RNAO