#Ontario is trying to deploy 385,000 rapid antigen tests per week in #LTC homes for asymptomatic #COVID19 screening: news.ontario.ca/en/release/603…

This is a bad idea for several reasons—not only is this infeasible, but it will be practically impossible for most homes to complete.

1/9
Currently asymptomatic staff undergo weekly PCR testing, much of which is completed on-site at #LTC homes and testing is staggered throughout the week.

Essential family caregivers complete PCR testing off-site at assessment centres or pharmacies (some are done at homes).

2/9
A shifts towards rapid antigen testing will require testing 2-3x/week (in Yellow/Orange/Red/Grey high prevalence zones) or 1x/week (in Green zones): health.gov.on.ca/en/pro/program…

The high frequency of testing compensates for the test's poor sensitivity: bmj.com/content/372/bm…

3/9
Since swab collection requires a regulated healthcare professional, a forced move towards rapid antigen testing will exacerbate the existing staffing crisis in #LTC homes.

This comes at a time when homes are already overburdened with vaccine rollout and managing outbreaks.

4/9
There are also substantial concerns about increasing unpaid time for #LTC staff—there are no concrete plans to compensate these already underpaid workers to show up early for work 3x/week to complete their rapid antigen testing (and await results before entry into a home).

5/9
There are other logistical issues. Homes estimate they will each need 2 full-time equivalent staff on a 24/7 basis to operate rapid antigen testing—where are these staff coming from and who will pay for them? If extra staff can't be hired, resident care could be compromised.

6/9
Space is also a big problem in already overcrowded #LTC homes. Where do staff wait to be tested or for results (before they start their shift)?

The Ministry suggested staff wait in their car...reality check...many staff can't afford their own cars and take public transit.

7/9
There is also the cost for biohazard waste, and it's unclear how homes will oversee the entire process (all positive results still need to be confirmed with PCR testing).

The Germans have called rapid testing in #LTC homes "easier said than done": ltccovid.org/2020/11/24/rap…

8/9
I understand the outrage over the underuse of rapid tests, but we should not be forcing these upon a vulnerable, understaffed and overextended LTC sector, especially when there is no clear evidence that a shift to rapid testing will prevent outbreaks: tvo.org/article/heres-…

9/9

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More from @NathanStall

18 Nov 20
In the last few days and following the emergence of #COVIDzero, I've noticed an unsettling fissuring within the academic community.

As @IrfanDhalla says, people on both sides likely agree more than they disagree, but the divisiveness is unproductive: thestar.com/life/health_we…

1/8
The #COVIDzero approach recognizes that there is a disjointed approach to #COVID19 in Canada that is causing uncertainty, unnecessary suffering, economic hardship, and preventable deaths.

#COVIDzero is based on a goal of 0 cases with 0 tolerance for community transmission.

2/8
The "moderate" or "balanced" camp scoffs at this aspirational strategy, minimizing it to "hashtags and platitudes...on social media", highlighting its impossibility, and contends that we need to focus on "improving our ability to live with #COVID19": nationalpost.com/opinion/opinio…

3/8
Read 8 tweets
16 Nov 20
New @medrxivpreprint (not yet peer-reviewed) with @KevinAnBrown and colleagues examining temporal variations in the intensity of care provided to the 2,000 Ontario #LTC home residents who died of #COVID19 between March 11th and October 28th, 2020: medrxiv.org/content/10.110…

1/6
While there was no official policy denying hospitalizations media reports (cbc.ca/news/health/co…) & testimony from Ontario's LTC COVID19 commission (ltccommission-commissionsld.ca/transcripts/pd…) suggest that resident transfers to hospital were strongly discouraged at the onset of the pandemic.

2/6
To investigate this, we measured monthly variations in hospitalizations among community and #LTC-dwelling Ontarians who died of #COVID19 between March-October, 2020.

We found that monthly hospitalization rates were relatively stable among community-dwelling individuals.

3/6
Read 6 tweets
9 Nov 20
Our study led by @KevinAnBrown associating crowding in #Ontario nursing homes (defined as the mean number of residents per bedroom and bathroom) with #COVID19 infection and mortality has now been published in @JAMAInternalMed: jamanetwork.com/journals/jamai…

1/9
We analyzed #COVID19 incidence and mortality data for residents of nearly all of Ontario's 623 nursing homes from March 29-May 20, 2020.

As of March 29th there were 78,607 residents in these homes, with 36.9%, 37.3%, and 25.8% in single, double, and quadruple-bedded rooms.

2/9
As of May 20th, 5218 (6.6%) residents developed #COVID19 infection, and 1452 (1.8%) died of #COVID19 (case fatality rate = 27.8%).

#COVID19 infection was distributed unequally across Ontario's nursing homes, with 4496 infections (86%) occurring in just 63 homes (10%).

3/9
Read 9 tweets
4 Nov 20
Yesterday, despite rising #COVID19 cases, hospitalizations, and deaths in LTC, Ontario released a framework to "keep the province safe and open": news.ontario.ca/en/release/590…

This is nothing more than an ageist, ableist & unethical "shielding" or "focused protection" strategy.

1/12
A "shielding" or "focused protection" strategy (the latter was popularized by the Great Barrington Declaration: gbdeclaration.org) segments the oldest and most vulnerable to #COVID19, while allowing everyone else to resume life as normal with simple hygiene measures.

2/12
As many have already highlighted, the #Ontario framework establishes a very high threshold for closures and lockdowns: cbc.ca/news/canada/to…

Specifically, the 10% test positivity and incidence rate ≥100/100,000 thresholds for return to a modified stage 2 are very high.

3/12
Read 12 tweets
4 Nov 20
Manitoba's Health Minister called out the "motivation" of >200 doctors who wrote an open letter calling for stronger action: cbc.ca/news/canada/ma…

Remember @CameronFriesen called care home deaths "unavoidable"—let me explain how when it comes to #LTC he hasn't "got this".

1/9
Let's review the escalating #COVID19 catastrophe in the province's care homes.

There are 14 active #LTC home outbreaks and 38 cumulative resident deaths. Today the @redcrosscanada was called into Parkview Place and Maples, the two hardest hit homes: cbc.ca/news/canada/ma…

2/9
Earlier this year, @LTCcovid published international examples of measures to prevent and manage #COVID19 outbreaks in residential care and nursing home settings: ltccovid.org/wp-content/upl…

#Manitoba is failing miserably on almost every key measure.

3/9
Read 9 tweets
18 Sep 20
In the last 24 hours, two more Ontario #LTC residents died of #COVID19: ottawacitizen.com/news/local-new…

There remain 22 active Ontario #LTC home outbreaks (see figure).

@ASPphysician has challenged me to say what must be done to get this under control.

Here it is (a thread).

1/8
We need swift action to control community transmission of #COVID19 which is getting out of control.

In our @CMAJ study, the prevalence of #COVID19 in the community surrounding a home was strongly associated with the odds of an outbreak (aOR = 1.91): cmaj.ca/content/192/33…

2/8
Controlling community transmission is imperative, as staff neighborhood characteristics are also significant predictors of outbreaks: medrxiv.org/content/medrxi…

As @DFisman showed, lagged staff infections were associated with death among #LTC residents: jamanetwork.com/journals/jaman…

3/8
Read 8 tweets

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