The 2021 AMR Preparedness Index is an excellent effort to look at what is 1 of our most pressing public health issues as some countries emerge from the COVID-19 pandemic: #AntimicrobialResistance
There are important findings for Canadians and their leaders: 1. We ain't so good!
2. We are behind the UK, US, France, Germany, India and Japan on a national strategy.
"Governments must make bolder financial investments ...
... should develop more ambitious National Action Plans and provide sufficient funding to achieve goals ... lean into AMR initiatives now"
3. We are kinda pathetic on governments' commitments to foster and support AMR innovation.
Govts "should implement pull incentive programs within the next 3 years ...
increase investments in AMR innovations for surveillance and diagnostics ...
ensure pricing reflects full value"
4. 🇨🇦 govt effort to reduce overuse of ABx and promote rational Dx is relatively poor, behind most peers.
Govts should "provide better access to diagnostic tools for general practitioners ...
improve enforcement and administration of existing mechanisms ...
fund ... stewardship"
5. Canada's attention to managing antimicrobials throughout their life cycle, including disposal, is amongst the worst.
"should better integrate environmental controls in ... National Action Plans ...
continue to integrate the One Health approach"
6. 🇨🇦 govt has far to go with facilitating collaborative engagement to address AMR
"should provide more direct support for research institutions and working groups ...
partner with NGOs ...
"invest in training next gen of AMR researchers and clinicians to support clinical trials"
Conclusion: "Though Canada has demonstrated strong implementation of training, awareness, and healthcare infection prevention programs, investments in innovation and commitments to national strategy are lacking."
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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.