My biggest concern in Toronto at present: the public doesn't understand the acuity of the situation, and are therefore understandably upset at current developments. So I will try and outline my understanding of the current situation:
Testing: we have a 7-day average of about 240 cases/day. This is an underestimate of the number of tests, because of a) backlog, b) system challenges that are dissuading people from being tested, c) over-weighing of younger cases, which makes asymptomatic cases more likely.
Regardless, our testing system is overwhelmed, and so we have no gauge on our gas tank.
The number of cases has totally exhausted @TOPublicHealth capacity.
. So not only no gas gauge, but we also don't have a map for where we are going.
On top of this, b/c our society has been pretty unfettered and free, most cases have had > 20 people who they were in close enough contact with in the days prior to being tested/symptomatic. This is a major challenge for not only contact tracing but, more importantly, for growth.
As the growth of cases increases, it means possibly an "essential" worker is out of commission. Or they are introducing it into a nursing home. Which is a big deal, because we now have 45 nursing homes in ON in outbreak.
This is a big deal because many patients who are in hospital are waiting to be transferred to a LTC bed. That list is growing, and will grow exponentially. That will further strain hospitals, which is already at the breaking point in Ottawa, and we are at 90% capacity in TO.
growth of cases and the ↑ strain on hospitals will mean surgeries and other non-emergent healthcare will suffer, as everything backs up further. Who will provide all this care? Same workers who are getting infected.
Additionally, as these cases rise, we have more schools in outbreak mode. This will mean more kids at home, and their parents (read "some who are healthcare workers or teachers") at home.
This is why we are at a critical time in our city's (and province's) history. Even if most infected don't go into hospital or die, the effect on the entire system is massively profound, and cannot be ignored. Israel and European cities like Madrid have discovered this already.
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.
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.
"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.
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.
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.
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)
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.