Letter from an Infectious Diseases Specialist Email #23
Dr. Andrew Morris is a Professor in the Department of Medicine, Division of Infectious Diseases, at the University of Toronto, and a consultant in Infectious Diseases and General Internal Medicine at Sinai Health System (SHS) and University Health Network (UHN). He has been sending weekly email since our quarantine started in response to the dozens of personal emails he got from his network. You can follow Andrew on Twitter at @ASPphysician. I am sharing this with you so 1. You can be informed by the experts rather than Facebook groups 2. You can make a decision that is right for YOUR family.
I am a girls’ basketball coach who doubles as an infectious diseases physician, and this is my 23rd weekly email since the COVID-19 pandemic emerged.
As is the norm recently, there just seems tons for me to share with you (and here I was thinking that I was going to be done writing these emails by August). In fact, I won’t cover everything that people have written to me about. This week I will cover back-to-school (again, with some additional commentary addressing concerns from emails I have received from the United States), screening & surveillance, Ministries and Public Health, Ryan Reynolds and Seth Rogen, dentistry, and the Hammer and Dance.
Back to School: This has been and continues to be hotly discussed. In the US, some kids have already gone back to school. At the time of this writing, the Ontario Government has responded to tremendous pressure and freed up reserve funds (i.e. not really committing substantially new money) for hiring more staff, freeing up more space, and improving ventilation, and acknowledged that more work is needed to make schools safe. Additionally, on August 14, Toronto’s Medical Officer of Health wrote a letter to the Provincial Government and the Toronto Catholic District School Board (in response to their respective plans). I am pretty pleased to say that it is almost 100% compliant with what I had suggested in my 21st and 22nd emails regarding school opening, and thus I am 100% in support of their recommendations that include:
- Class sizes that allow physical distancing of 2m
- Prioritized attention to the most vulnerable neighbourhoods/schools in Toronto
- Novel approaches to testing to make classes safer
- Screening for symptoms prior to appearing on school grounds
- Masking for all children, at all ages where possible (with scheduled breaks from masking, preferably outdoors)
- Delaying or staggering the school start until measures can be put in place
It does not include my suggestion of physical barriers such as a plexiglass shield and use of a microphone to separate teachers from students when speaking loudly at the front of the class. Regardless, if all of these measures are adopted, I would feel we have a really robust back-to-school approach. Because disease prevalence is so low in Ontario, we do have some wiggle room, but it would be unwise to bring all kids back to class without having these measures in place. The decision to send your kids back to school—yours alone—just please make it recognizing that, presently, the anticipated risk of kids getting infected at school in September (and probably even October) is going to be quite low, and the risk of them getting quite sick is markedly lower than that.
All of the above recommendations apply equally to the United States but the risk assessment is very different. In most jurisdictions in the US, disease prevalence is unacceptably high. It is definitely on a downward trend in many US states, but it is not low enough in my opinion to make school attendance a low-risk activity uniformly. I think it makes sense in NY, NJ, MA, RI, VT, CT, and probably MI. On the other hand, it is still prohibitively high in AZ, CA, FL, TX, WA and and almost everywhere else in the US. The same, therefore, goes for US colleges as well—we are already seeing multiple outbreaks on US campuses already.
Screening and Surveillance: I have brought up screening and surveillancerepeatedly over the months. It is increasingly clear that one of the best ways managing this pandemic until we have an effective vaccine widely administered is going to be testing people to identify who is infected before they infect anyone else. This is—like with most things COVID—controversial. Some people argue that with so few people currently infected in Canada, you are far more likely to test someone and falsely identify them as infected (when they are not) than you are to catch someone and prevent further infection. There is some truth to that.
The simplest means of screening for infection are temperatures checks (but they are entirely useless in my opinion) or asking people daily about symptoms. I am unsure if asking people daily about symptoms are helpful—once you have awareness, those who have symptoms and are willing to do the right thing will stay home, regardless if whether you ask them. (If I were to ask about symptoms every day, I would ask: fever, cough, sore throat, muscle aches, vomiting, and diarrhea; I might throw in loss of smell, but I think those first ones are sufficient. It will probably over-call symptoms, but better to prevent an infection. I think.) Perhaps more importantly, many infected people have few if any symptoms.
Technology also currently exists to identify when we need to scale up more intensive testing. In some states, they test wastewater regularly for the presence of virus—so you know when virus is circulating in a community. That might tell you when you need to test individuals more intensively. We also increasingly have the ability to test pools of people to just see if, say, a class is infected. We have known how to do this for months, but it is still not being done in most places. I have already stated that we need to do this kind of testing for schools (as has Toronto Public Health), but I will get to that next.
Ministries and Public Health: Many of you are not inclined to understand governmental structures. I don’t blame you, to be honest, because it can be both confusing and frustrating. Over the years, I have been privileged to meet some really great politicians at the municipal, provincial and federal levels. I have some favourites (but I am not telling!) But we have a real challenge: there are Provincial Ministries of Education and Health—who also oversees the Provincial Health Labs and COVID testing, via Public Health Ontario—and then there are the municipal/regional public health units (PHUs) and school boards (e.g TDSB). I am a huge fan of the head of our Provincial Health Lab, Dr. Vanessa Allen, but she is administratively disconnected from the PHUs and school boards. Accordingly, we have zero certainty at present around how testing (again, Public Health Ontario) will be fit into the back-to-school schedule, and it is even unclear to me if the province will allow school boards to dictate anything on their own. What does this mean? If there were an agreed upon plan in place and negotiated between all players, parents would know and understand what is happening at their kids’ school. But for now: it is a growing and unmitigated disaster lacking clarity, with parents and kids (and teachers) caught in the middle. The only solace: our current infection rates are low. Ryan Reynolds and Seth Rogen: As you know, they are both famous and from Vancouver. I personally think Seth is hotter. Vancouver (and BC in general) is currently struggling, with a rapid rise in cases and being on-target for a rough September. Not good. The stats show that young adults are to blame. So what to do? Focus on young people. How? Enlist people who are cool. Which is what John Horgan, Premier of BC did, reaching out to Reynolds and Rogen. One response:
Mission accomplished. Or close enough. But this should not be the end of it. We need the same all over Canada. We actually need a national campaign with the likes of Drake, Alessia Cara, Connor McDavid, Sandra Oh, The Weekend, etc. getting young people to a) stay away from big crowds, b) physically distance, and c) wear masks. This should be accompanied by changing by-laws or creating spaces where young people can drink, party, and enjoy life safely outdoors. Help them make better decisions.
Dentistry: The WHO came out with a really poorly worded recommendation about dentistry and its lack of safety. It clearly wasn’t meant to apply to Canada. Ignore. Go to your dental appointments without worry.
The Hammer and the Dance: Tomas Pueyo, early on in the pandemic, wrote about how to control COVID in a series of articles on medium.com, including the one titled The Hammer and the Dance. The premise: when you have a big surge, the only way to appreciably deal with it is with a massive public health response; but once you get it under control, then you are in a constant tit-for-tat as you try and keep large waves at bay. Whether this is true or not is being tested, as Japan and Spain see cases rising dramatically as they struggle to avoid needing a hammer. As you know, Victoria, Australia is employing a hammer, as is New Zealand (not because their numbers are high, but because they believe that it the goal is total elimination of the disease by means of a hammer). I have had several discussions with people over the last while who have felt that my viewpoints are a) unreasonably strict or b) have mellowed and are more “balanced”. I assure you, they have not changed at all. When numbers are anything but really low with low replication as well, then we need pretty aggressive measures—especially with the support of public health—to make the case load manageable. But once we are where we are currently (i.e. low number of cases), then we need to figure out “the dance” to see what we can open up safely. We are clearly dancing these days. I hope we continue to dance over the ensuing months. Just not in crowded nightclubs.
p.s. As always, feel free to share to whomever might benefit from the emails and/or follow me on Twitter (@ASPphysician).
League of Moms / 08/20/2020