March 6, 2020 COVID-19 report

Happy Friday RNAO members,

A reminder of RNAO’s updated daily communications for this second month of the COVID-19 outbreak in Canada: You are receiving summary updates on Tuesday, Thursday, Saturday and Sunday – inclusive of Ontario’s Ministry of Health’s Emergency Operations Centre (EOC) Situational Report, and World Health Organization (WHO) Situational Report. In addition, you are receiving on Monday, Wednesday and Friday, longer updates such as the one you are receiving today, which may include an RNAO policy corner and more detail. To see previous updates visit RNAO updates and resources on COVID-19 for members and other health professionals. Feel free to share any and all updates with other health professionals at home or abroad.

Brief Update on Repatriated Canadians: Canadians from the Diamond Princess cruise ship, who arrived on Feb. 21 from Japan and are in Cornwall were released today of their quarantine period. We wish them a safe return home as they adjust to their normal lives. To date, there are no COVID-19 positive cases among the repatriated Canadians from Wuhan who were quarantined at CFB Trenton or who are currently in quarantine at the NAV Centre.

MOH EOC Situational Report #41 here, inclusive of important materials: 1) A Must Read Memo from our COVID-19 Command Centre Leadership and 2) Self-monitoring fact sheet in Farsi. The number of confirmed cases in Canada reported by EOC today is 48 cases. Also, EOC reports that in Ontario, at this time, there are 78 persons under investigation with lab results pending.

Since we received the EOC report, we have received media updates of new cases. As we stand, Ontario reported five new cases today (28 total), British Columbia reported no new cases (21 total), Quebec reported a new case (3 total), and Alberta reported one new case (2 total). This brings Canada to a total of 54 cases (up from 45 yesterday). Of particular concern is the case reported in BC, yesterday, believed to have been contracted through community contact. “This is a community case, and we are doing a detailed investigation right now to try and determine where her source of infection was,” said Provincial Health Officer Dr. Bonnie Henry. This would mean a new evolution of COVID-19 in BC.

Colleagues, our stakeholder Collaboration Table discussed today communications – both for health professionals and the public –, and there is accelerating progress. The issues we hear are important and enable us to advice the Command Table regarding the field’s needs. At yesterday’s meeting, RNAO raised issues related to 1) PPE (the need to have evidence-based guidance on when to use surgical masks versus N95), 2) the need for mobile mask testing (for walk-in and small family practice clinics), 3) the need to work on virtual care modalities (to assess, monitor and support patients in self-isolation), 4) the need to immediately designate hospitals with an attached overflow assessment centre, and 5) the need to continue educating the public on prevention through respiratory hygiene. We also need to enroll the public into understanding and demystifying what a “scenario B” will look like should there be spread in the community and should we enter a pandemic phase. The Command Table and the regional tables are working intensely on these and other issues and we will keep you informed.  

I want to give a shout-out to the media, which has informed factually and responsibly. The media plays a central role in providing solid information to the public, and preparing the public, in a calmed way, for an eventual community spread. See our participation in CBC The National.

Public Health Ontario maintains an excellent resource site on materials on COVID-19. Very useful are the materials on What We Know So Far About… Coronavirus Disease 2019 (COVID-19). These documents are intended to provide an overview of knowledge on the subject, done through ongoing scanning of the published literature, scientific reports, as well as media articles. Current topics include: zoonotic origins, infection in children, risks to health care workers, fecal-oral transmission, bloodborne transmission, incubation period, as well as asymptomatic infection and transmission. More generally, the Public Health site is an essential resource for Ontario health providers; I encourage you to visit it. 

Another essential resource is Health Canada's website on COVID-19. It 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.

Please note that the Public Health Agency of Canada has released guidance for schools (k-12) and childcare programs (COVID-19), see here.

Situation Report 46 from WHO updates that worldwide there are 98,192 confirmed cases (2,873 new) and 3,380 deaths (99 new) in 88 countries (4 new). 95% of the new cases are outside China. There are 6,284 confirmed cases in South Korea (518 new). Other countries to note are Italy (with 3,858 confirmed cases, 769 new), Iran (with 3,513 cases, 591 new), Germany (with 534), France (with 420), Japan (with 349), Spain (with 257), USA (with 148), United Kingdom (with 118) and Singapore (with 117). In all these countries the main form of transmission is local. The total number of confirmed cases aboard the Diamond Princess cruise ship is 696. Four new countries (Bhutan, Cameroon, Serbia, and South Africa) have reported cases of COVID-19 in the past 24 hours.

You can also find up-to-date global numbers in Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE.

Real-time training is critical for effective preparedness and response. WHO has several COVID-19 online resources for health professionals, decision-makers and the public in multiple languages. Please see the COVID-19 courses on OpenWHO here.

Infection prevention and control (IPC) is a major factor in preventive and mitigation measures for COVID-19. To ensure evidence-based quality guidance and prompt response to global demand for personal protective equipment (PPE), WHO has convened the IPC expert global network of specialists from around the world since the beginning of the outbreak. In consultation with this global IPC expert network, WHO has released three key IPC interim guidance materials. One of these is the Rational use of personal protective equipment (PPE) for COVID-19. This document summarizes WHO recommendations for the appropriate use of personal protective equipment (PPE) in health care and community settings, including the handling of cargo. In addition, OpenWHO launched the online course Infection Prevention and Control (IPC) for COVID-19 on 25 February which is being widely used.

Critical: Please review the proper donning and doffing of PPE; guidelines can be found here.

Q&A: Similarities and differences – COVID-19 and influenza (from WHO here):

As the COVID-19 outbreak continues to evolve, comparisons have been drawn to influenza. Both cause respiratory disease, yet there are important differences between the two viruses and how they spread. This has important implications for the public health measures that can be implemented to respond to each virus.

Q. How are COVID-19 and influenza viruses similar?

Firstly, COVID-19 and influenza viruses have a similar disease presentation. That is, they both cause respiratory disease, which presents as a wide range of illness from asymptomatic or mild through to severe disease and death.

Secondly, both viruses are transmitted by contact, droplets and fomites. As a result, the same public health measures, such as hand hygiene and good respiratory etiquette (coughing into your elbow or into a tissue and immediately disposing of the tissue), are important actions all can take to prevent infection.

Q. How are COVID-19 and influenza viruses different?

The speed of transmission is an important point of difference between the two viruses. Influenza has a shorter median incubation period (the time from infection to appearance of symptoms) and a shorter serial interval (the time between successive cases) than COVID-19 virus. The serial interval for COVID-19 virus is estimated to be 5-6 days, while for influenza virus, the serial interval is 3 days. This means that influenza can spread faster than COVID-19.

Further, transmission in the first 3-5 days of illness, or potentially pre-symptomatic transmission –transmission of the virus before the appearance of symptoms – is a major driver of transmission for influenza. In contrast, while we are learning that there are people who can shed COVID-19 virus 24-48 hours prior to symptom onset, at present, this does not appear to be a major driver of transmission.

The reproductive number – the number of secondary infections generated from one infected individual – is understood to be between 2 and 2.5 for COVID-19 virus, higher than for influenza. However, estimates for both COVID-19 and influenza viruses are very context and time-specific, making direct comparisons more difficult.

Children are important drivers of influenza virus transmission in the community. For COVID-19 virus, initial data indicates that children are less affected than adults and that clinical attack rates in the 0-19 age group are low. Further preliminary data from household transmission studies in China suggest that children are infected from adults, rather than vice versa.

While the range of symptoms for the two viruses is similar, the fraction with severe disease appears to be different. For COVID-19, data to date suggest that 80% of infections are mild or asymptomatic, 15% are severe infection, requiring oxygen and 5% are critical infections, requiring ventilation. These fractions of severe and critical infection would be higher than what is observed for influenza infection.

Those most at risk for severe influenza infection are children, pregnant women, elderly, those with underlying chronic medical conditions and those who are immunosuppressed. For COVID-19, our current understanding is that older age and underlying conditions increase the risk for severe infection.

Mortality for COVID-19 appears higher than for influenza, especially seasonal influenza. While the true mortality of COVID-19 will take some time to fully understand, the data we have so far indicate that the crude mortality ratio (the number of reported deaths divided by the reported cases) is between 3-4%, the infection mortality rate (the number of reported deaths divided by the number of infections) will be lower. For seasonal influenza, mortality is usually well below 0.1%. However, mortality is to a large extent determined by access to and quality of health care.

Q. What medical interventions are available for COVID-19 and influenza viruses?

While there are a number of therapeutics currently in clinical trials in China and more than 20 vaccines in development for COVID-19, there are currently no licensed vaccines or therapeutics for COVID-19. In contrast, antivirals and vaccines are available for influenza. While the influenza vaccine is not effective against COVID-19 virus, it is highly recommended to get vaccinated each year to prevent influenza infection.

The time now must be divided into 1) continuing to prevent, or at least delay, the spread, and 2) preparing all sectors for a possible large-scale spread so we are confident we can effectively respond. Thus, we urge you to continue to educate yourself and others on how to diminish the risk of transmission. You can see the WHO recommendations for prevention here.

Continue to keep us informed of questions and/or challenges of any kind, and especially shortages of PPE. Send these to me at dgrinspun@rnao.ca. 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. We also have information for the public on our website at www.rnao.ca which we update daily. The WHO has provided an excellent link for you to share with members of the public here.

Lastly, make sure you also rest and relax. COVID-19 will likely be with us for a while, so it is important that we work hard to be ahead of the curve, and also take care of ourselves. The European Centre for Disease Prevention and Control states that “Unfortunately, it is not possible to predict how long the outbreak will last and how the epidemic will unfold. We are dealing with a new virus and therefore a lot of uncertainty remains. For instance, it is not known whether transmission… will naturally decrease during the northern hemisphere summer, as is observed for seasonal influenza.” Check this here.

RNAO’s COVID-19 Mantra: Let’s remain informed, calm and resolved – through collaboration we will tackle the COVID-19 challenge together! 

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