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)
3. We also are suggesting that—in addition to considering inhaled budesonide (800mcg bid x 14d) for high-risk pts. with mild illness—that fluvoxamine 50mcg --> 100mg tid for 15d be considered.

We aren't certain these work—and fluvox needs pharmacist consultation and F/U but ...
4. we think that the potential benefits outweigh the harms, and they are both RELATIVELY cheap and available at present.
5. Because we are concerned about supply of tocilizumab and sarilumab, we have also added the option of baricitinib 4mg daily for moderately and critically ill
Along with our health system partners, we will be monitoring supply and demand carefully in the coming weeks to adjust our recommendations.

In the interest of timeliness, some supporting literature will be coming out AFTER appearing as a summary here. Sorry!
As always, this is the collective work of many volunteers on the @COVIDSciOntario Drugs & Biologics Clinical Practice Guidelines Working Group, along with many partners who have provided important and meaningful feedback.

Summary design, as always, by the brilliant @tiffany_kan.
Complaints, gripes, disagreements?—happy to hear, learn, and discuss.
Compliments, gift cards, Raptors/Leafs/Drake tix (after team is at full strength and safe to do so)?—send them to amazing Co-Chair @MPaiMD (and ask her to share with me).

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More from @ASPphysician

5 Dec
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
24 Nov
So much talk about introducing 3rd doses in Canada. This hits close to home because ... I live in Canada!

But I have lived in LMIC, have a parent from a LMIC, and believe that vaccine equity is incredibly important.

Nevertheless, widespread 3rd doses are getting pushback. 🧵
1. Do vaccines work and vaccine efficacy wane?
Hell ya! We have tons of data demonstrating this. Here is just one figure from @FT that shows waning immunity (and then booster effect).

Yes, mRNA is better than AZ, but both wane from their peak efficacy d/t decr neutralizing Abs.
This paper from @ScienceMagazine yesterday (science.org/doi/10.1126/sc…) shows that nAbs are the 💣 when it comes to protection from COVID-19.
Read 18 tweets
13 Jul
Really important study looking at daily sampling of early SARS-CoV-2 infection in 60 individuals, focusing on viral shedding for up to 14d. medrxiv.org/content/10.110…
Lots of stuff to learn here:
1. Sore throat, runny nose, and muscle aches had strongest relationship with positive viral culture.
2. For most individuals, nasal VL > saliva VL and viral shedding peaks at least 1d earlier in saliva vs. nasal.
3. Viral load is not perfectly predictive of infectiousness.
*4. Massive (i.e. 40-fold) heterogeneity in individual level infectiousness, with imperfect correlation with age. This means that features of the "the spreader" can be a very important contributor to superspreading.
5. No clear explanation of increased transmissibility of VOCs.
Read 4 tweets
23 Jun
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"
Read 7 tweets
17 May
To my colleagues & trainees who have contacted me in distress over the past few days, I see you and hear you.

I don't post my thoughts about the Middle East because—even though I have studied its history tremendously over the years—I recognize that there are more than one truth.
I understand how you fear—as Jews or people sympathetic to the tragedy that Israelis are experiencing—expressing your views or trying to counter views that see only one side of a dispute that is much older than the state of Israel.
I also understand how uncomfortable you have been made to feel when colleagues or supervisors use their (mostly) professional platform to acknowledge the unquestionable and tragic suffering of Palestinians yet fail to acknowledge the suffering many Israelis are also experiencing.
Read 9 tweets
9 May
Reluctantly, I feel I need to clarify some issues around why AZ doesn't make sense for most of Canada right now.

When NACI evaluated—using the hard endpoint of deaths—the risk-benefit of AZ vs. no AZ, it used a lower incidence 1 per 100 000.
With this modeling, it makes clear sense to give AZ vs. waiting for age 50-69 in a moderate incidence setting, and for all ages in high incidence setting.

But what happens if the VITT rate is 1:26 000 or 3.85/100 000? You get this ...
This means that it is only a slam dunk (vs. no vaccine) for age 50+ in high incidence (30 cases/100K/day) settings, and 40+ in very high incidence (60 cases/100K/day) settings. Even if VITT incidence is 1:40 000 (or 2.5/100K/day), your expected VITT deaths/100K are 0.63-1.0.
Read 9 tweets

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