Letter from an Infectious Diseases Specialist Email #25

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 you can be informed by the experts and make decisions that are right for YOUR family.



I am a girls’ basketball coach who doubles as an infectious diseases physician, and this is my 25th weekly email since the COVID-19 pandemic emerged. 

This week I am going to address our winning, back to school for (kids/parents and teachers), COVID surveillance, and why you need bug repellant.

We have been winning:  Fortunately, despite all the missteps, we are definitely winning currently.  (We had roughly 750 documented cases in Ontario last week, which means that we had somewhere between 3500-7500 infected people in the province, as most infected people go undetected.  This is a remarkably low number in a province of over 14 million people.)  I continue to believe that opening bars and nightclubs was an unnecessary risk to take, and I do fear that we will see a substantial rise over the next couple of weeks, but we are doing better than I anticipated and I am really happy to be wrong on this. (As a former trainee reminded me on Twitter this week, I constantly tell people that I am in the business of being wrong.  In fact, I am wrong so often, you should wonder why I am still gainfully employed.)  The reasons we are doing so well are both multiple and unknown.  They can include strong masking policies throughout the province, responsible behaviour by the majority of citizens including doing more stuff outdoors, and a stronger and more data-driven public health response since May.  Having low numbers allows Public Health and laboratories to keep things under wraps.  It is unlikely to continue at this really low rate, but I believe we can actually tolerate higher numbers than we did in the Spring because we have a much greater ability to arrest transmission cycles: finding cases quickly and preventing them from spreading elsewhere.

Back to School:  I was hoping to avoid discussing it again this week … but not a chance.  As school start dates get closer, it is getting real for kids, parents, teachers, and other school staff.  Much of what is occurring in Toronto, at least, are things I advocated with my very first posting on this:  targeting vulnerable neighbourhoods (and I point you to two recent articles addressing the importance of this – Kelly Grant’s in the Globe and Mail which includes many of my own words, and Lauren Pelley’s on CBC.ca), considering testing pools (being piloted by Toronto Public Health), and doing everything possible to reduce prolonged, congregated and crowded, unprotected, face-to-face, indoor contact.

I read last night that more and more parents are strongly considering keeping their kids at home.  I continue to believe that this is a parental position and nobody else’s, but I worry that it is based less on fact and more on fear.  First, please look at our overall numbers and look at the numbers in your neighbourhood.  Chances are, there are very few people who will enter your kid’s school infected.  On top of that, screening, masking, distancing, cohorting, and other efforts will dramatically reduce the likelihood of a kid in school infecting somebody else.  Further, Ontario’s current approach is that a new school case results in the class being quarantined.  This will arrest the transmission cycle—probably altogether.  It is very possible that your kids and their teachers will not be as safe at school as they will be over the next several weeks.  I am NOT excusing the very poor planning by the Provincial Government, nor am I telling you what to do.

Back to School (Teacher Edition): If you are anxious, I get it.  If you are scared, I get it.  If you don’t feel that working under less-than-ideal circumstances is right for you, I get it.  Teachers were really influential in my life, and you are really important and influential to our kids’ lives.  I hope you don’t feel left out in the discussion.

COVID Surveillance:  I was happy to see that Sharon Kirkey’s article in the National Post on Health Canada’s refusal to consider home testing received widespread attention.  We need much much much better surveillance moving forward.  The truth: we are mostly relying on people presenting to testing facilities or mobile testing units with symptoms.  We can do better.  What should we do?

Do you know that game where you hide “the treasure” and then tell the person that they are getting “warmer” or “colder” depending on how close they are getting to what is hidden.  They have no idea what or where they are looking, but the other participants help the “finder” know where to look.  Right now, our public health officials are trying to find the treasure without finders.  Management of infectious diseases have long used such finders, including sentinel chickens to help us be on the lookout for West Nile Virus and Avian Influenza.

1.     We should strongly consider wastewater testing: the idea is that you can see detectable virus in communities before needing to test people.  It can give you an idea into where you need enhanced testing.  This is probably most important when there are barriers to identifying symptomatic cases—communities reluctant to be tested, and young kids who often don’t display typical symptoms.

2.     We should pool saliva testing in schools, universities, and congregate workplaces. Collect samples from a bunch of people, pool them together, and see if there is virus in that group of people.  You could test, say, 1000 people running 100 tests … the scalability is huge.  You may not yet know who is infected, but you will be much “warmer”.

3.     We do large-scale point-of-care testing performed by nurses that will give a result in minutes.  Abbott in the US just signed a deal with the US govt. for 150 million of such tests.  The ones approved relies on a nasal swab, not saliva, but the results come back in 15 minutes, and will dramatically improve testing capability in the US.  I believe such tests need a confirmatory test, but those will be in much fewer cases.  We need such a test in Canada, but there is little prospect for that in the immediate future, unfortunately.

4.     We get at-home testing when it is available.  I discussed this last week.

For now, we are left with waiting for people to develop symptoms and go for testing.  Governments need to understand that surveillance and health care are not the same thing, but that starts with not treating them the same.

Wear Bug Repellant As you have heard from me repeatedly, being outside is much safer than being inside as it relates to COVID-19.  This does not mean that being outside is 100% safe.  One of the potential risks of being outside is West Nile Virus (WNV).  WNV is an infection spread through mosquito bites.  By testing mosquito pods, we know how much WNV is around.  The answer, at the moment, is quite a bit.  We just don’t yet know if that will translate to infections.  I have seen several already.  I hope we don’t see many more cases but, regardless: if you are going to be outside at dawn or dusk—cover up or wear insect repellant.

I will stop there, hoping that you all enjoy the upcoming week and look forward to school restarting.

Andrew

p.s.  As always, feel free to share to whomever might benefit from the emails and/or follow me on Twitter (@ASPphysician)

You can read Andrew’s previous here and here

League of Moms / 09/01/2020

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