Letter from an Infectious Diseases Specialist

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 and 3. If you agree with Andrew then this is your chance to contact your MPP, Stephen Lecce and Doug Ford. Will anything change? Who knows, but if there was ever a time to stand up for our kids and teachers I believe it is now.

I am a girls’ basketball coach who doubles as an infectious diseases physician, and this is my 21st weekly email since the COVID-19 pandemic emerged. 

I am just starting my week off, but because I am getting even more emails and inquiries than usual, I am happy to provide this email to you all.  As usual, please feel free to spread widely.

This week’s email is jam-packed because there seems to be so much going on.  I am going to focus on children and schools, recreational sports, the COVID app, and Australia.

Children and Schools: This is top of mind for many people.  Parents, because they want their kids in school but are often understandably anxious about it.  Teachers and other school staff, because this puts them directly in the line of fire.  Everyone else, because a functioning society requires schools.  I have some colleagues that are fairly opposed to school restarting, and I don’t share their beliefs.  School should start as soon as it is safe to do so, preferably 5 days/week for kids under 14 or so.  (Disclosure: I provided input to the recent guidance document from SickKids.)  The key is “as soon as it is safe to do so”.  That requires a few things:

1.     Low community prevalence of disease with little community-based disease transmission (i.e. there is little COVID going around):  this is an absolute criterion in my mind, and we meet these criteria, unlike almost everywhere in the US, which is why you should ignore much of US discussion on this topic at present.

2.     People (i.e. kids or grownups) must not be coming into school infected.  This is our Achilles heel.  The government has been coy about testing and surveillance which generally means they haven’t done anything about it.  There are many ways to do surveillance.  The easiest is syndromic surveillance—whereby schools or school boards screen people daily at entry to school about symptoms, and also keep track of why people are absent, and note trends.  This is a bare minimum in my mind.  Rather, I believe they need to do pooled testing for classrooms (i.e. they get a pooled sample from, say, a quarter of people in a classroom and then test the single sample to identify if there might be an infection in the classroom (when they would then test each person in the class).  This requires high levels of coordination and organization, but good syndromic surveillance is probably the second most important step prior to being able to get school to start.

3.     Structures and systems have been put in place to reduce the major risks for disease transmission—large numbers of people, indoors, in close contact (which are the characteristic features of most classrooms).  So every school must put every effort to spread kids out in class, optimize outdoor activities (especially September to mid-November), reduce class sizes, and improve classroom ventilation.  This requires tons of creativity, but it can be done. Convert gyms, libraries, lunch rooms, to classrooms.  There are lots of unused or underused buildings now.  Churches, Mosques, Synagogues and Temples; Community Centres; etc.  Optimize existing technologies.  Consider tweaking school hours.  Reevaluate the entire school year—these are extraordinary times.  They have a month to plan—and the work needs to get done.  (Trust me—it is amazing what can be achieved in a month if the effort is placed there.)  Lunch time, snack times, etc. are where there needs to be a particular focus.

4.     “Transmission barriers” should be included in each classroom.  The simplest form is having a plexiglass barrier in front of a teacher who is speaking with a shield on AND is using a dedicated teacher-only microphone to amplify their voice.  Loud speaking spreads disease, and I also think it is important that students see the teacher’s facial expressions.  Getting teachers to speak louder defeats the purpose.  This isn’t easy but it is doable.  The barrier will also protect the teacher for some of the time.  Additionally, as much as possible, kids should have their face covered.  My preference is, for a variety of reasons, face shields as you know—they are less obtrusive, and will reduce risk.  They need to go down low enough on the face (below chin), but they are good for kids.  If schools normalize this, I think it could be easily worn by all schoolchildren of all ages.  I want to emphasize—and this is key—that this is 4th on the list for a reason.  The recent “masks4all” movement has been good—and has my support—but they are far less important than keeping socially distant, reducing crowding, and minimizing indoor interactions.

5.     Figuring out what to do when someone is infected (presumed or confirmed).  This is huge.  What happens if a kid has to stay home with a fever?  Or a teacher?  Who replaces the teacher? What if a child of a school teacher has to stay home? What if a classroom has several cases—what does the school do?  I am presuming that there are going to be VERY FEW cases of other viral infections going around.  If there is non-COVID virus circulating, “Houston, we have a problem”.  Because COVID actions should get rid of most circulating viral infections.  A very mild flu season in the Southern Hemisphere has proved this.

Needless to say, this is very complicated.  I don’t believe the Ontario government is making the necessary investments to make this occur.  They need to—it remains, in my mind, priority number 1.  If you are asking me if you should be sending your kid to school: I think at present the answer is mostly yes—for most people—but this will be fluid and depends upon personal circumstances.  If you should happen to be a teacher, the answer is even more complicated.

Recreational Sports:  Let’s start off by saying that the greatest risk for disease transmission in sports does not occur on the court or field.  It is in the changeroom, in the “huddle”, in carpooling, etc.  Major League Baseball has proved this already—they are in major jeopardy of collapsing within 2 weeks of resuming play while players are naturally distant from each other on the field.  If you have been following me regularly, you know that prolonged exposure timeindoorsin close contact is what will facilitate transmission.  After observing this disease intensely for 6 months, I can say that that is a pretty rock-solid heuristic for disease transmission.  So non-contact outdoor play is entirely safe: baseball and softball, tennis, track and field, beach volleyball are all fine.  Outdoor sports with brief intermittent contact are probably also fine at present: say, lacrosse, road hockey, outdoor basketball—but this is because prevalence of disease is low.  Indoor play might be safe if there is little crowding and little prolonged exposure, but the problem occurs around prolonged close exposure.  The contact doesn’t matter, but the close proximity for a prolonged period of time does.  So I would say no to squash and racquetball, but indoor tennis is ok.  Swimming is fine.  I think ice hockey is probably ok, to be honest.  The big question: basketball. I think basketball teams can safely practice indoors, with drills only.  But competition or scrimmaging—I don’t know if this can be safely done until we have a better handle on disease surveillance.  It doesn’t bode well for competitive basketball which I believe is probably one of the highest risk sports—up there with football and rugby (which are both outdoor sports)—with Basketball Ontario already postponing any competition until at least January 2021.  As a parent AND youth basketball coach, my thoughts are:

1.     Yes, this sucks.

2.     I know you think your little (or big) baller is going to make the WNBA or NBA, but another 9-12 months of not playing competitive hoops won’t matter that much in the long run.  The best chance of them getting back to play competitively is really getting and keeping this disease under control.

3.     I have thoughts on how I will teach hoops and fitness this year—assuming I get a gym permit!—and it will be very different, but the girls will be even better than people might assume.

4.     No, I am not sharing my secrets with opposing teams/coaches.

COVID Alert App:  No doubt you have heard of this app (Download COVID Alert today – Canada.ca).  This app integrates with your phone’s Bluetooth technology and—if your Bluetooth is kept on—it will let you know if you have had high risk exposure to someone who has tested positive.  I think the idea is great, the interface is easy, and the privacy guarantees are top notch, which is why I encourage you to go and download it immediately if you have not already done so.  HOWEVER, this will not be a replacement to public health contact tracing, testing, and isolation.  There will be glitches with it along the way (for example, what do healthcare professionals do with this information if we were notified that we were exposed to COVID-19 and we cannot know if it was one of our patients who we knew were infected or a totally separate exposure).  Regardless: get it.
Download COVID Alert today – Canada.caPublic Health Agency of CanadaCOVID Alert: Canada’s contact tracing app to stop the spread of COVID-19

Australia: The southern Australian state of Victoria is on lockdown again, and it is instructive for us in Ontario.  In many ways, Victoria is like Ontario, and Melbourne is like Toronto.  (You could make the argument that it is Sydney and New South Wales, but I spent formative years in Melbourne, so I am sticking with the Melbourne-Toronto analogy.)  Melbourne had a smallish spike in March-April, kept it largely under wraps until mid-June, and since then has seen classic exponential growth.  (Remember what I wrote about exponential growth—at first, it seems like no big deal, so you don’t want to over-react, but then it goes gangbusters.)

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As of today in Melbourne, they have declared a “State of Disaster” (which is worse than a “State of Emergency” by the way) imposed a curfew of 8pm to 5am unless you do essential work; otherwise, from 5am-5pm you can leave your home for a) work, b) getting food and essential supplies within a 5km radius of their home (only 1 person per household), or c) a maximum of 1h exercise (within 5km radius); face coverings are mandatory everywhere outside of the home.  THIS is why we cannot normalize our behaviours.  Keep your social circles small.  Avoid prolonged time indoors in close contact with other people.  If you are sick, get tested.  Get the COVID Alert app.  Keep taking this seriously—because there is a reasonable chance that we will be Melbourne.

Final thought: We are not even half-way through battling this.  Guaranteed.  I hope the next 6 to 9 months are better than the last 6.  When we get a Health Canada-approved vaccine, I will be getting it as soon as I can.  Older adults, frail individuals, intellectually disabled, economically disadvantaged, racially marginalized, immigrants and refugees, migrant workers, meat packing plant workers, homeless, mentally ill (including those addicted to substances): these are the main victims of COVID.  You wanna bitch and complain about lockdowns, restrictions, etc. then do something to support these groups.  By all means, please be selfish and worry about yourself—but do it by dealing with these groups.  Oh, and one last thing (even though I am really worried about the health of the Jays):  Go Leafs Go! Go Raps Go! Go Jays Go!


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 / 08/05/2020

9 thoughts on “Letter from an Infectious Diseases Specialist”

  1. Great insight and thank you for sharing your knowledge.
    Also, Go Argos! I fear for our CFL league.

  2. Thank you for this helpful information. I am a retired elementary teacher with 14 years of my career teaching Kindergarten. Since FDK began, my class size was always 30+ children. I am extremely worried about the return to school plan of the Ford government.

  3. What are your thoughts about kids participating in dance class? My daughters studio is opening and I would like them to go because they didn’t get to finish their season or have their recital. But only if it is safe to do so. The studio is ensuring that social distancing will be maintained and between classes everything will be disinfected. They aren’t planning on having kids and teachers wearing masks though unless the teacher needs to assist the student like in acro for stunts.

  4. Thank you so much for your info. I am a teacher who is quite anxious as I had heart surgery in July 2018. I am afraid I am putting myself at risk, but I really want to be teaching!

  5. Could you please clarify if you mean face shields over face masks, and any evidence (eg % transmission reduction) you are aware of regarding the benefits of face shield compared to face masks. I have some parents asking about face shields as an alternative to those kids who are not able or willing to wear a mask.

    Thank you. MM

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