Hamilton Primary Care Town Hall Q&A, November 18, 2020

Is there a provincial repository where COVID vaccinations can be recorded/viewed once it becomes available?

• If by repository one means a vaccine registry, no, such as comprehensive registry that can input all the data on COVID vaccinations delivered and viewed by multiple, relevant audiences does not yet exist, see Bob Bell’s OpEd in today’s Globe.

If public health has had such a problem with distributing the flu shot when extra was ordered, how is there any hope of a smooth rollout of the Covid vaccine? How is PH going to roll out the COVID vaccine?

• How the COVID vaccine will be distributed within Hamilton once it is received is not yet known, as final decisions have not been made as to PH mass vaccination clinics vs. other delivery models, e.g. primary care, hospitals, LTC.  This is complicated by the vaccine storage and handling challenges of the new mRNA vaccines, especially the Pfizer product, that requires ultra-low temperature storage.

How long after positive COVID test can a patient get a flu shot?

• Not known at present.

What to do after getting symptoms?

• Get tested immediately and isolate until you receive results.
• COVID +ve:  If you test positive, Public Health will be in contact and provide you with next steps.
• COVID -ve: As the false negative rate is low, especially when tested at onset of symptoms (high viral load), it is likely that the result is accurate. Regardless of a negative result, you should continue to isolate if you feel unwell so as to not spread an infection that may result in others requiring isolation, testing, or an increased burden on the health care system. It was noted that sensitivity drops after day 5 of symptom onset, which means it is important to get tests immediately at symptom onset.

What is a close contact?

• A close contact could include a family member you live with but could also extend to someone you encountered within 2 m without appropriate PPE (i.e. someone you have lunch with), if that contact was with the case while they were infectious, i.e. 48 hours before symptom onset or during infectious period of acute illness, i.e. 10 days after symptom onset.  Basically, it is having contact with someone where you could have been exposed to infectious droplets without distancing or PPE.

Shouldn’t people with confirmed colds also be staying home, because the impact of spreading URTIs so large right now?

• Yes. It creates further implications and confusion.

What to do with people who have a runny nose or one minor symptom?

• It is important to remember that the recommendation that school aged children may return to school with a runny nose is based on evidence from that population and is not applicable to other populations, such as adult health care workers. If you have a symptom, regardless of how minor it may be, the recommendation is to get tested and not discount symptoms.

Are there false positives?

• 2 situations occur – a true false positive which is often due to a reaction at the end of the PCR where the primers start replicating, or an old positive which is someone that had remote COVID-19 (often unknowingly) and are still shedding dead virus.  Differentiating is based on history (prior illness or exposure), clinical (presence of infiltrates), and sometimes cycle thresholds or serology.  Either situation is non-infectious.

What is the false negative rate of the covid test?   Have had this happen to 2 patients, they were sick when went for initial test with fevers of 102.

• If the person is symptomatic and if the specimen was properly collected with the proper swab, especially for NP swabs, then the likelihood that this was a false negative is very low.  Our regional estimates of COVID PCR sensitivity is 90-95%.  However, if the clinical picture is compatible with COVID and the person is a close contact, then re-testing would be recommended.

Any news on vaccines?  Will family doctors be considered first line responders and receive vaccines prior first, similar to hospitalists?

• The NACI* prioritization of COVID vaccines includes HCWs in the first four high-priority groups, along with the elderly/those with co-morbidities, essential service workers and people living in institutions or remote communities.

*(National Advisory Committee on Immunizations – a group of scientists, clinicians and ethicists)

How long after testing positive can a PSW return back to work?

• 10 days after symptom onset as long as they are afebrile with resolving or resolved symptoms and don’t have underlying immunocompromise.

Have there been any new office cleaning guidelines published since the thinking has changed about the low rate of fomite transmission?

• Not that we’re aware of, although the fomite transmission risks are judged to be lower than originally thought this has not yet led to revised cleaning and disinfection recommendations.

We need help with creating safe spaces for our staff and also enabling them to communicate.
How far away is it safe to work unmasked with another person, e.g. 20 feet? or no distance is safe?
Can we erect plastic sheeting to separate staff and does this create a de facto ‘separate room’? 

• A variety of factors are important to consider when assessing office guidelines regarding when and where to wear masks:
  • Can staff be separate by at least 2m? If they are in their private workstations 2m apart from peers, they do not need to wear a mask. However, even if they are 2m apart from others but frequently access communal areas or equipment where 2 m distancing may be difficult (e.g. printer station, filing cabinets), a mask should be worn.
  • Are staff following safety measures outside of work? Risk of exposure within the office decreases if staff are following safety measures outside of the office. If staff are participating in riskier activities (i.e. car pooling without wearing a mask), the need to wear masks in-office is heightened. It should be noted that while research is indicating fomite transmission is not a significant source of transmission, IPAC procedures (i.e. cleaning and disinfecting) should still be taken seriously, particularly in common areas.
  • Does the office have reasonable ventilation? Check with your building manager to ensure the building HVAC system is working optimally.

Any guidelines with how many patients can be in an office crossing paths at the same time? If the HFHT could post any suggestions this would be helpful for scheduling and planning even per square foot.

• Again, the focus should be on active screening of all patients, masking of all patients and anyone accompanying them, if symptomatic and in for assessment have them booked at a time when other patients are not present, have dedicated exam rooms for these patients and pathways to these rooms that avoid crossing paths with others.  Rate of transmission for incidental passing of someone is exceedingly low, especially if all are masked.

The OMA and HFAM have put forth guidelines for in patient visits, which essentially include everything, is that not inconsistent with the current code red?

• The OCFP document below from June provides very sound guidance and was shared by the OMA on Nov 18 and this, as well as Ministry of Health guidance and the WO/SWO pandemic response team, is also the basis for the HFAM recommendations

• The “Red” phase addresses social exposure that is volitional; care in the office can be delivered safely and the potential negative consequences of deferred care are often much greater

How significant is runny nose and nasal congestion as a symptom

• Amongst adults runny nose and/or congestion which is NEW should be considered as a potential symptom and may warrant testing

We’ve had some patients who get a swab and then we never see the results and when contacting public health there is no way to trace where that swab went – after their isolation period they return to regular activities but patients and family are quite frustrated by these events.  Is there a process for recording where the swabs go so we can trace back?

• Can be a difficult challenge, as the provincial testing network may be sending a swab taken in Hamilton to a lab in another community if our local lab is overloaded or having technical problems, e.g. an analyzer is malfunctioning.  Can be difficult to trace where the specimen was analyzed, but the results should appear on the provincial portal.
• This is more of an issue outside Hamilton; the concern has been escalated at the provincial assessment and testing tables

Do we have the current capacity to contact trace effectively both locally & provincially?

• There are currently locally challenges to do all contact tracing in a timely manner due to the volume of cases and the # and type of contacts for each case, especially re: following up with a contact within 24 hours and have needed to prioritize contact notification (including having some of our cases notify their own close contacts at least initially)

Rapid test – costing

• Mobile PCR tests (Abbot ID Now amongst others) can get a result in 15 minutes, with high specificity. To use this equipment, training and lab designation are required. The government has approved the use of mobile PCR tests and will be sending most of them to remote communities and smaller hospitals with high testing delays and facilities experiencing outbreaks needing to undergo serial testing.
• Another POC antigen test involves an NP swab that is then loaded onto a pregnancy test-like instrument. The sensitivity of this test is lower (70-75%), resulting in an increased likelihood of false negatives. This type of testing may be used ins settings requiring serial testing.

Children are being sent home from school and daycare and when parents try to book test online they don’t qualify?

• The on-line booking system may reject a parent request for testing if the child had only one symptom, based on the revisions to the school COVID screening process
• The on-line booking does give the parent the option to book but advises it is not indicated

Is days of quarantine going to 10 days or staying at 14 days? can we confirm isolation rules — is it 14 days if asymptomatic, and 10 days from onset of symptoms? I get confused as I hear 10 and 14 days

• COVID +ve patients will continue to shed the virus 7-10 days from symptom onset, resulting in the need for them to isolate for 10 days once their fever is resolved without anti-pyretics and their symptoms are improving or have resolved.
• If you are exposed to a contact, the maximum incubation period is 14 days, resulting in a required quarantine of 14 days.

A link to the latest Ministry guidance document for these (and guidance for health care workers) is found under “When to discharge from isolation or consider  “resolved” in the management of COVID section on HFAM.

Will the new study results from airport swabs, showing people generally test positive within 7 days if they are going to be positive, change our quarantine duration for community contacts?

• For travel-related quarantine – may shorten duration to 7 days plus a test to release into society – Calgary is using a day 2 strategy and this is being looked at for Pearson/land borders.  For non-travel-related quarantine (exposure) the same approach is being used for 14 days, knowing that some people can be symptomatic late

What should our hospital physicians do when their child is tested positive and they are asymptomatic with negative testing?  Lots of confusion and different advice from different hospitals.

• If the parent is a close contact (a virtual certainty), then they need to quarantine for 14 days from their last exposure.  It is recommended that they be tested during this period if they develop symptoms, or if asymptomatic at least once in the latter half of the 14 days to make sure they have not contracted an asymptomatic infection.  95% plus of close contacts who develop COVID infections do so within 11 days, but the full 14 days of quarantine (also referred to in Ontario as self-isolation) is required, unless they are considered a critical worker.  In this instance the physician can return to work under work isolation. The close contact must remain asymptomatic for work isolation to occur.

Regarding safety in the workplace: We have a large open admin/RN area.  My understanding is that if staff are in the same room, even if room is large and they are 10 – 15 feet apart, they should be masked. Is this correct?

• If staff can maintain a 2 m or more separation during work, they do not have to wear masks.  Remember there are also other safeguards in the office environment, especially active screening of staff, masking while away from their workstation, hand hygiene and respiratory etiquette.

Are there any effective treatments for COVID-19 in the community- i.e. puffers, dexamethasone, Zithromax etc.?

• None other than supportive management.  Manage the complications, but dex has a trend to harm in the non-oxygenated

The saliva test that is being run at St Jo’s and can be self-administered (also the test used at the airport?) – why isn’t that used more widely, instead of the NP swabs?

• Nasal and oral swabs are viable alternatives.  Some centers are using saliva as a diagnostic modality (Sick Kids) – but this requires a lot of reprogramming of devices and workflow issues.  Each lab will have their own preferences.

I have had a lot of patients lately come in with valved masks. Should we be disallowing valved masks as they don’t provide source control?

• Yes, valved masks are not acceptable source control.

Is there antibody testing studies for patients following positive covid infections?

• Yes – we have a study for those who are positive or negative to find their status – only criteria is having a test done.  Please email me (chaglaz@mcmaster.ca) for details.

What does red mean in terms of office workflow?

• Neither the coloured system not the Ontario Optimizing Care system contain information and recommendations for health care offices. However, a red designation is a result of increased COVID cases, meaning that there is an increased likelihood of patients with COVID entering the office (asymptomatic or symptomatic). Safety protocols and IPAC guidelines must be followed.
• Throughout all colour stages, it is imperative to review basic principles, such as screening of patients and staff, physical distancing measures, PPE, etc.

Routine wearing of PPE:

• It was noted that the hospital standard of care requires a surgical mask.
• As all patient should be wearing masks in the ambulatory environment, risk of exposure and need for alternative PPE is reduced. However, if your patient has suspicious symptoms or refuses to wear a mask, additional PPE (i.e. googles) is reasonable.
• It was noted that gowns are only required for droplet and fluid exposure and that gloves do not add much protection beyond good hand hygiene.

Any guidelines with how many patients can be in an office crossing paths at the same time? If the HFHT could post any suggestions this would be helpful for scheduling and planning even per square foot

• Answered above

Red Zone allows sports and activities outside school etc. to continue, when would this change?

• There are additional restrictions on sports and activities in the grey/lockdown stage. Please refer to the provincial framework.

Long COVID:

• New research identifies those most at risk from ‘long COVID’ Kings College London
• Need to be careful looking at literature for long symptoms (causality may not be explicit).
• If seeing patients: check for diagnosis and check for alternative causes. If you are sure its long COVID, ensure patients that most people do improve over time.
• More research is being done to understand Long COVID.
• There is some initial guidance from the UK for the primary care approach here
  (click Management of COVID tab, at end of section you will find heading “Long COVID: Management of Post-Acute COVID Symptoms”)

Is there anyone specialists locally who is dealing with post-covid symptoms

• Dr. Angela Cheung at UHN
• Dr Michelle Kho, Research/PT at SJHH

Is it safe for a pregnant nurse positive and symptomatic to go back to work to an outbreak nursing home? after 14 days.  She still does not feel good

• If you or a staff member feel unwell please continue to isolate so as to not spread an infection that may result in others requiring isolation, testing, or an increased burden on the health care system.

Pregnant women working in COVID outbreak floors? any restrictions?

• No obvious restrictions – information shows complication rate similar to non-pregnant and vertical transmission is incredibly rare

Is antibody testing an option for patients who has ILI early on and did not have option for testing and are now unwell from resp standpoint with sob and desaturation and are now unwell-

• Possibly – is available from PHO with call to microbiologist.
• See hfam for guidance document and contact details

What is the length of time for COVID-19 results now?

• Have been under 24 hours, this has gone up slightly due to a malfunction in the lab but still favourable.