A Communication from Dr. Chris Mackie on Friday, March 13, 2020

Dear Friends, Partners, and Citizens,

Today marks a turning point in the Coronavirus/COVID-19 response in Canada. Our public health leaders are truly adapting in a meaningful way to the World Health Organization’s announcement this week that this has become a pandemic.

New Strategy

This announcement means that there is no doubt that COVID-19 is coming to our communities, and our focus is shifting. Public health is still working toward preventing as many cases as possible, but we also need to come to grips with the fact that many of us will be affected. (Though for the record, claims that up to 70% of people in Canada could be affected are simply wrong. The worst case scenarios in history all point to much lower spread for this sort of illness, even for brand new viruses.)

Crucially, the overwhelming majority of us who become sick will not have any serious long-term consequences. Case fatality rates of about ~3% have been reported in some places, but the best estimates for established and well-organized healthcare systems in developed countries put the death rate closer to 1% or less. The level of illness is comparable to the flu. A sick person may have a rough time for a bit, but generally, they will recover quickly and move on. This means that we should be turning our attention toward how to best protect the most vulnerable in our communities.

Containment efforts -- where public health isolates cases and contacts with the goal of preventing community spread -- will continue, but they are likely to only slow the onset of a local outbreak. The goal now is to prevent as many poor outcomes as possible. This means that resources need to be refocused on those who are most vulnerable -- older adults and people with significant chronic disease -- and to maintaining a high-functioning healthcare system.

Mass Gatherings

Fortunately, decisions are now being made that will really help:

• Ontario is keeping schools closed for an extra two weeks after March Break
• Ontario, Quebec, BC and Alberta have all cancelled mass gatherings over 250 people
• Universities and colleges are taking classes online, and cancelling major events
• The NBA, NHL, OHL and NBL Canada have suspended their seasons; this dramatically reduces the number of very large gatherings where one person could potentially infect many. Concert and conference promoters will need to look at this in the coming weeks.

The extended March Break announced yesterday by the Provincial Government is a fantastic move (though inconvenient for many). This will delay the onset of Ontario's epidemic wave, and the closer we get to summer the better, as weather may help. Other coronaviruses spread much less in summer months. This March Break decision isn’t just cancelling of mass gatherings, it also serves as a de facto quarantine of returning travellers.

All of these steps, and more, will blunt the peak of the epidemic here. They will slow spread, allowing the healthcare system a chance to keep up with the increased demand.

Here is a federal guidance document on assessing risk for mass gatherings.

Change in Provincial Testing Policy

Other difficult but necessary changes will help keep our communities strong. In Ontario, testing for Coronavirus will now, more or less, be reserved only for those who are sick enough to be hospitalized. Healthcare workers and Indigenous people on reserve will also be prioritized.

This change in the testing policy is big. Family doctors in the community will not be able to offer or order the test, and people in the emergency room won't be tested either unless they are sick enough to be admitted to hospital.

It is important to note that there is no specific treatment for Coronavirus. Testing an individual will not help them get better sooner. In the current pandemic, testing is useful mainly for identifying cases to help with containment and the reality is that we will soon be past the containment phase.

So at this point, testing each person who is ill doesn't really help that person, but it does consume precious system resources. All people with significant respiratory illness should be taking similar public health steps to those who are diagnosed with Coronavirus: wash your hands often, and stay home until you are better.

There will still be hundreds of tests performed in Ontario in people in hospital, and in healthcare workers. This will continue to give us clear and timely information so that we can see how things are progressing.

What to do if sick

For sick people, the key things to do will be:

• Drink fluids until your pee is clear. This helps your body fight the infection. Drink water, Gatorade, and yes, chicken soup.
• Rest and stay home. Take care of yourself, and don't infect others.
• Tylenol or Advil may help you feel a bit better.
• Go to the hospital only if you are very ill.

A major factor in how this plays out will be whether, or not sick people take the necessary steps to prevent the spread of their infection to others.

If you are mild to moderately ill, especially with a fever, please stay home. Reach out to friends, neighbours, etc. if you need help to stay home. We'll do our best to be there for you.

If you are severely ill, consider going to hospital. Examples of when to go to ER:

• Short of breath/trouble breathing
• So exhausted that you physically can't get out of bed
• High prolonged fever not responding to Tylenol
• Chest pain

Here’s an article with more on when to go to ER. When in doubt, in Ontario call Telehealth at 1-866-797-0000

What others can do to help prevent illness

For people who are well:

• Wash your hands often, of course!
• Try to avoid touching your face with unwashed hands. It's hard, but it's important to prevent contaminating yourself and others.
• Cough into your sleeve, not your hand.
• Consider avoiding mass gatherings for now.

Employers, you play a major role.

• Ensure people have access to hand washing.
• Ensure high-touch areas (e.g. washroom door handles) are cleaned often.
• Ensure staff stay home when they are ill and provide them with financial support to do so. It’s cheaper than all your staff being off at once because someone worked while sick, or having a bad outcome in one of your team.
• Encourage visitors to your business who are ill (customers, contractors, vendors, etc) to delay their visits.

Change in recommended personal protective equipment (PPE)

Another long-awaited change: we are moving to droplet precautions in Ontario. Coronavirus is definitely spread by droplets, primarily from sneezes and coughs, which project about 1-2 metres. The droplets do not float in the air like chickenpox or tuberculosis (TB). They drop. That’s why they’re called droplets. To be clear, this disease does not spread by the airborne route.

This means a surgical/procedure mask gives good protection to clinicians examining sick patients, and an N95 respirator is unnecessary and unhelpful. Ontario had been requiring N95's in the healthcare setting out of an abundance of precaution. This was never sustainable, and research clearly shows it's not needed. Of course, gloves and/or handwashing as appropriate, and additional PPE for those involved in aerosolizing procedures such as bronchoscopy.

Everyone has a role

At this critical juncture, YOU are a key part of the puzzle. How will the leaders of our community and the general public react to these changes? Can we step back from our natural tendency to miss the forest for the trees? Can we accept putting the most vulnerable people's needs above our own? Can I see that a decision that may not help me as an individual is important to help us as a community? Can we live our values of ensuring that care goes to those who need it most?

Supporting a friend or neighbour or family member or colleague can make a big difference. And it's something that we as Canadians are good at. You might give someone the help they need to stay home and not spread illness to others. Or you may be the one who is ill, and takes steps that save a life of someone close to you.

I think we can do it. I think we will live up to our Canadian reputation for being a kind and caring people. I think we can get through this together.

Go team!
Sincerely,
Chris

Christopher Mackie MD, MHSc, CCFP, FRCPC
Medical Officer of Health
Middlesex-London Health Unit