Andrew Morris Profile picture
Mar 24, 2020 8 tweets 6 min read Read on X
Why does global governance of infectious diseases matter? Let's talk about how we are going to get out of the #COVID19 #COVIDtorium with a thread on getting back to normal.
@LabonteRonald @shoffmania @ColleenFlood2 @picardonhealth @BogochIsaac @drsanjaygupta
Step 1 will be to get agreement on what is #COVIDfree. We usually decide that occurs when the appearance of disease goes back to "baseline rates". In the case of #COVID19, this will mean 0--unless it has developed the ability to mutate and becomes endemic or seasonal (like flu).
To be able to state that we are at zero, will require surveillance and case-finding, as beautifully discussed today @globeandmail by Michael Wolfson theglobeandmail.com/opinion/articl…? But this will require standards @AccredCanada @HSO_world @WHO to be set and agreed upon.
Taking our feet off the gas pedal with social distancing will threaten to delay getting to zero. Without getting to zero, we will not be able to comfortably get out of #COVIDtorium, and we will not be able to get to Step 2. There will also be pressure to prematurely let up--dont
Step 2 will be that countries will re-open internal life according to their local epidemiology. If cities are totally shut down, they will gradually open them up and try to get back to normal.
Step 3 will be that borders will open up. When will those be opened up? When adjacent jurisdictions are #COVIDfree. If trade and travel depend on being declared #COVIDfree, there will be a strong motivation to meet these standards.
The problem: this will most harm the countries who are least able to declare themselves #COVIDfree: low- and middle-income countries. With our currently globalized world, there is economic need to help these countries. Regardless, ethically, it is our obligation.
Life will return to a #newnormal when more and more countries can reliably and verifiably claim that they are #COVIDfree. This will almost certainly will require international agreements and governance for infectious diseases...which takes time and should be pursued immediately.

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More from @ASPphysician

Feb 24, 2022
Yesterday, @COVIDSciOntario released updated treatment guidelines, focusing on patients with mild illness. It is a substantial change from prior guidance, so we thought we would walk people through the noteworthy changes.

You can find the document here: covid19-sciencetable.ca/sciencebrief/c…
First, as always, this is the work of +++people incl. the, er, volunteers of the Drugs & Biologics Clinical Practice Guidelines Working Group of @COVIDSciOntario. Co-chair is @MPaiMD.

Second, the update is a response to:
1. New data & evidence
2. Changes in drug supply & demand.
The first thing you will notice is that we have done away with Tiers (cue the cheers), and instead have put in a grid that takes a more nuanced approach to risk for disease.

[NEW] We are now aiming for treating pts whose risk of progression is comparable to ~5% hospitalization.
Read 12 tweets
Jan 22, 2022
🔥JUST RELEASED: New clinical guidelines for COVID now including #Paxlovid (nirmatrelvir/ritonavir).

A 🧵 on why Paxlovid is NOT first-line.

covid19-sciencetable.ca/sciencebrief/c…
"W-w-wait! Paxlovid is NOT first line? I thought everyone was saying this is the best thing since the mute function!"
You have it right. If you look carefully at our guidelines on the 2nd page (where we cover outpt therapy for "Mildly Ill Patients") you can see where it lies.
"That is waaaay too small to see on my phone."

Sorry, let me try again.

"Oh, I think I can see. So Paxlovid is only for the highest risk patients, and only if they cannot get sotrovimab or remdesivir?"

That's right. And in Ontario, we don't have enough remdesivir for outpts.
Read 18 tweets
Jan 8, 2022
Clinical Practice Guideline Summary: Recommended Drugs and Biologics in Adult Patients with COVID-19 - Ontario COVID-19 Science Advisory Table covid19-sciencetable.ca/sciencebrief/c…
The guidelines are based on a blend of pathogenesis, clinical trials, and local realities of drug supply and burn rate.

If we got it right, phew!
If we got it wrong, recognize that this is a rapidly evolving situation, with new evidence, new variants, and new drug availability.
Omicron has shortened the presymptomatic period, but we have little certainty of the rest of the time course.
Read 25 tweets
Dec 28, 2021
I have received messages, texts, and reply-tweets regarding my stance on COVID management in ON (and elsewhere). As a strong early proponent of a #COVIDzero approach for a variety of reasons which, I believe, will show merit historically, I have never minimized COVID. However ...
1. I continue to have uncertainty regarding the severity of Omicron. I believe we will establish considerably more certainty in days ahead. Certainly, some evidence is emerging of a lesser severity—both mechanistically & epidemiologically—but I remain uncertain and thus cautious.
2. I don't accept the experience of the UK, Denmark, or anywhere else right now because they are at roughly the same time period in Omicron as we are—very early. The reasons why we cannot generalize from Gauteng are well documented, including in my weekly newsletter from Dec. 18.
Read 18 tweets
Dec 22, 2021
The latest COVID Therapeutics Guidelines from @COVIDSciOntario are now available here (covid19-sciencetable.ca/sciencebrief/c…)

Lots of new stuff, so let's take a drive ...
1. The dominance of Omicron in cases means that the monoclonal antibody cocktail of casirivimab + imdevimab is no longer useful. It is sotrovimab or bust!
2. Because we don't have tons of sotrovimab, we are recommending it for the groups most likely to gain overall benefit.
These are symptomatic mildly ill patients who are:
70+ years with 1 additional risk factor
50+ AND Indigenous + 1 additional risk factor
Residents of LTC or other congregate care
Hospital-acquired
* other high-risk patients can also be considered (e.g. +++ immunocompromise)
Read 8 tweets
Dec 5, 2021
A few thoughts on the anticipated Omicron wave:

1/ People are increasingly fed up with COVID, so measures to control Omicron cannot/should not rely on measures used for prior waves. (Which means that governments would be wise not to allow COVID to reach a crisis situation.)
When I highlighted several days ago that case growth was worrying me, several Twitterati assumed that I was alluding to lockdowns. (I was doing nothing of the sort)

But failure to pay attention to cases in EUR shows that countries can be forced into lockdowns if they don't act.
2/ Engineering/environmental controls (e.g. ventilation, filtration) will be the smallest imposition on people's lives.

Better masking (understanding, adherence, quality) would make a difference.

This is without assuming any properties of Omicron.
Read 13 tweets

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