COVID19 update

Sunday, March 29, 2020

Covid19 update Mar 30, 2020

  Premier Ford has extended the Emergency Order in Effect for Ontario till at least April 14, 2020.  This implies that everyone should stay at home and not venture out unless it is an emergency.  For those worried about coronavirus, please take the following assesment quiz,  https://covid-19.ontario.ca/.

We will continue to work in isolation, and provide services.  We will accomplish as much as possible by phone, fax and other remote means. Messages will be returned.  For urgent medical matters we will arrange specific assesment times.  Those with fever and infection will be triaged elsewhere until protection equiptment arrives.Please continue to practice social distancing and good hygiene. 

We continue to remain under an emergency order to remain at home, maintain proper hygiene and distancing.  I am very impressed with how our political and medical leadership have responded to the Covid19 situation when compared to our southern neighbours, who continue to bicker and fight amongst themselves, while the situation continues to peak and the economy suffers.  Seeing our prime minister on television daily, giving a calm and responsive approach, is helpful. The opposition support this effort. A similar approach is taken by the premier, and the head of my own OMA has been relentlessly mobilizing efforts and providing validated information. The medical community is mobilizing. Locally, we are preparing to bolster and support innitiatives and we will be redeployed to aid  hospital congestion. 

   I am dissappointed how the numbers are broadcast like a factual hockey score. Simply reporting how many positive swabs were processed in a day, and how many deaths occurred without context leads to fear.  The numbers are very complex and different. For numerous reasons, you cannot compare countries around the globe without considering complex variables. Much more context is needed around these numbers. This creates a fear, and overloads hospitals. It is drying up supplies needlessly that may be needed later.  There  is a fear based demand for testing and the results show that only about 3% are positive, and most of those are sent home.


COVID19 update

Sunday, March 29, 2020

Covid19 update Mar 30,2020 

   

    I saw a somewhat distressing advice given by a hired medical source on a national news network, that suggested that people leave their homes and run out to get a flu and pneumonia shot.  I disagee and thought sharing some insight may help. A quote from en-slaved poet Taras Shevchenko states; "to overcome an adversity, first learn all you can about it".  There is a big difference between bacteria and viruses.  Bacteria are the car, and a virus is the bolt on a wheel.  Viruses are very simple and microscopic.  Coronavirus, has a bit of RNA in it, a lipid coat with some protiens on it. That's it. If you disrupt the coat with alcohol or soap, it becomes non functional and decomposes. DNA analytic techniques may find the "remains" weeks later, but cant tell if the virus is alive or dead. Hence rumours of persistence are born. Dead viruses dont infect. At any given time, our skin, and external body cavities are colonized with hundreds of different bacteria, fungi and viruses.  Our skin and innate immune system keep it all in balance.  It takes a minimum infective dose to create infection.   For coronavirus, this means that you need a large number of virus being delivered to the lung simultaneously. It could be dozens or thousands.  One particle on an egg carton dosnt stand a chance.  This is why health workers are more at risk. When an infected patient coughs, they are capable of spreading a million virus particles in every salivary droplet expelled. It's the natural course.  If these are directly inhaled and reach the lungs, then a new infection can occurr.  It is important to understand the life cycle of respiratory and cold viruses.  When a large particle  load reaches the lungs, our first line of defence kicks in.  These immune cells try to create an unfavourable environment to reduce replication, and buy some time for our immune factories to design specific killer antibodies.  This general response produces inflammation via particles called cytokines and interleukin.  We can feel this going on, with fever, sore throat, muscle aches, chills and fatigue.  The virus wants to borrow lung cells, and use their machinery to produce more viruses, which will be expelled with coughing.  In some people this immune response is quite substantial.  When you get inflammation around lung alveoli, which is a very thin area that transfers oxygen to blood, this oxygen transfer is difficult to occurr.  People whose immune systems are not up to par, have a delay in producing viral antibodies, and  this first response persists longer.  This can produce Acute Respiratory Distress Syndrome.  Oxygen or a respirator can enhance this needed oxygen transfer and if the antibody response catches up, things will get resolved.  However, many people with other medical disorders and poor lifestyles experience more severe effects.  A flu-shot will afford some immunity to some influenza viruses and none against coronavirus.  The pneumonia shot is designed for bacteria, and may help when bacteria overwhelm natural defences and enter the blood. 

 

    Having coronavirus on your body, clothing or other object is not too worrisome.  It is when you bring substantial amounts to your mouth that can cause problems.  Hand washing is a great idea.  Wearing a mask, when in close contact to people is also a good idea. For others it has the benefit of stopping unconscious mouth touching.  Full protective gear is recommended for those working with Covid19 infected patients due to the large virus loads involved.  

 

 


Covid19 update

Thursday, March 26, 2020

 

Covid19 Update March 27, 2020

       The whole world has changed in the last week.   I hope to provide some balance to the numbers for you.

    In Ontario we have about 837 confirmed corona-SAR2 virus illness.  13 people passed away.  In Canada we have 2,892 confirmed cases with 28 deaths.  Compare that to Influenz A&B which we have 52,526 cases with 97 deaths countrywide.  All these respiratory illnesses look similar and Influenza B is favouring the young.   Those that passed away as a rule,  had multiple medical conditions that they had been chronically struggling with and often required chronic care setting. The virus contributed to the death, but was not the sole cause.   Unfortunately, there will be the odd young healthy person that may succumb.   This will make the news headlines, so please keep things in context.   Most cases of respiratory illness are recovering at home.   In Ontario, we have conducted 38,550 swabs to date. These were sick people who were medically assessed prior to swabbing.   Only 837 tested positive.  No mention of what the other 37,713 patients had.  It underscores that respiratory viruses are largely invisible and symptoms look alike.   Most of the rest probably had influenza or a rhinovirus.   There is little use in asking to be swabed, except if you become critical.   The real numbers of how many cases are circulating is nothing but a guess.  You have to multiply the confirmed cases by a factor of 10-100 to ball park it.   It is analogous to counting how many fish there are in a lake, but fishing for 8 hours, and then using the number of fish you caught to estimate the real number.

    Many people misunderstand what the current emergency lockdown is meant to do.  There is a lot of unpredictable science at work, besides reminding us that grandma was correct about the washing, breathing and touching stuff.  Containment involves locking down a geographical area immediately to stop spread at the onset (i.e.dec19)  When China got overwhelmed and locked down millions of citizens, other countries were too nice to do the same.  I guess the lessons of SARS were forgotten.  Train, plane and ship travel continued for months,  until one world leader decided to follow suite and suddenly every other leader seems to think the same.  What academics realize is the current strategy of minimizing movement is  NOT aimed to erradicate the virus.  At best, it will slow the spread so that our medical system will not be overwhelmed.  Anyone who visits an Ontario hospital over Christmas witnesses how influenza paralyzes us annually.   It implies that the numbers will continue to keep climbing unless we find leaders who can crunch the numbers to real and definable things and provide comparisons to other diseaeses.   Good news is that greater than 99 percent of people do fine with respiratory viruses as a group.  We dont have a vaccine yet,  and there are medications that show some promise to help  those critical cases that require some assistance with breathing to recover.   Your best defence is your immune system.  Keep it healthy, eat fresh vegtables and fruit, avoid sugar particularly of the fructose variety. 

    Our medical center is now directly across from a Covid19 testing site. A lot of security, tape, tents, masks etc.  Please be assured that all proper precautions are being taken.   The emergency order, has resulted in more strigent refinements to provide health care.  Only essential care is being provided face to face.  Restrictions on telephone care have been temporarily relaxed to allow health care workers to provide care by phone.  We will screen all calls, and many patients will receive phone advice by one of our health team.   If you need to come in,  you will be given a specific time. Social distancing will be in effect, waiting rooms will be very limited.   Staff will remain behind glass shields. There is no need to produce OHIP cards unless changes .  Our lab and xray are only dealing with essential cases.   We have pretty well run out of most protective equiptment and cannot provide masks or  gowns.   We follow stringent disinfection between patients, and  ask that  you not dwell around the building and proceed directly home.   We are unable to see anyone with acute respiratory illness, and possible covid19 cases are being referred to public health.   We have NO SWABS.   This is not the time to deal with lists of minor issues.

 

 


COVID19 update March 21,2020

Friday, March 20, 2020

Covid19 update March 21, 2020

     Hope that you are all doing well. Covid19 confirmed by swab numbers are still creeping up, mostly because only certain group gets tested. It seems that the actual numbers are vastly higher with milder severity in our populations.  Influenza has slightly decreased.  People with  covid19 are not generally hospitalized or intubated, and we probably have numerous people who recovered and dont realize they had it.  We are not new to this by any measure. Theoretically, the same measures have been advocated to combat influenza viruses for the last 25 years.  I think it is a work in progress to learn how devastating this can be to the economy and peoples mental well being.  Vaccine is far from a miracle and work is going at a feverish level.  There is a huge monetary incentive to be the first in this regard.   More interesting is the discovery that more and more medications that we have used for other purposes can be used to decrease viral levels in an infected person so that the rare person may avoid a critical level.  This would be the best case scenario, as it would result in a good immune response by our immune systems. Almost sounds like a strategy mother nature would employ.

    Our medical building is on lock down for acutely ill people that fit the symptoms. They should be calling the health department hotline and going to a covid19 assesment center.   Testing is best reserved for those in hospital that require intense care.  Lets not forget that we are dealing with viruses that have a natural place in the world and are not trying to wipe out the human race. This is how viruses exist, and probably contribute some benefit to the human genome as a whole. One of the truisms in virology is that viruses which are too lethal, are not virtually invisible as this is. Ebola produces bleeding from all orafices, smallpox warns us with charactertic rashes.  A negative test, means you are sick with something else, and can't determine if you overcame corid or are still susceptible.

  More troublesome is the language used. "War has been declared, borders closing, people locking themselves in, hoarding supplies, arming themselves." I wont even start to mentions rumours coming from the those that should know better, that spur the mass hysteria.  Imagine, being a leaf fan, and the only hockey score ever announced was how many goals the leaf score. No mention of how many their opponents score or who won,  or other teams.  Stanley cup certainty mania would start for sure.

   I have been caught in this situation by being on the wrong side of the border when quarantine was announced, and now am working from an off site location in seclusion for 14 days.  On another positive note,  numerous organizations have come together including the CPSO, ministry of health, public health, OMA, CMA, CMPA to allow doctors to perform virtual medicine and phone assesments during the emergency measures.  Matters of confidentiality still matter, and it is recognized by all that advice can only be limited at best.   Despite contacting government stores for protective equiptment 6 weeks ago, it has not arrived and will not be arriving any time soon.  ie. the troops on the gound are trained and ready to go.  The have purchased their own equiptment, but alas, the requisitions for ammunition is still being considered, despite the battle has been ongoing for 3 mos.  This does not allow effective front line treatment of any air borne infections in the office setting.  Our staff and physicians will attempt to field your concerns for non infectious situations on a priority basis.  Leave a message on our phones, be a little patient and we will try to reach out, refill scripts, arrange procedures etc. for you during this time. In office policies will change soon to adjust to the numerous and ever changing guidelines which seem to changing on a daily basis.

   Please keep your wits about you. Keep those other illnesses under control, because that makes a big difference. We are here for you and we will get through this together.  But life will be different and there will be more challenges coming. 


COVID19 update March 15, 2020

Saturday, March 14, 2020

COVID19 update March 15, 2020

      Cold viruses have been circulating in the human population for millenia. We treat it like some enemy plot. Some believe that it is a symbiotic relationship. It was romanticized in the classic film "war of the worlds", where the simple cold virus saved us from alien invasion.  We have all inherited the genetics needed to allow our immune system to handle the virus. It is far more effective than any drug or vaccine.  What has not been publicized enough is that pretty well ALL people with mild to even severe symtoms survive.  They dont  need to clog the health care system.  Grandma's advice of using acetominophen for fever and pain, hydrating, using mentholatum to unclog nasal passages, lozenges for sore throat and eating very healthy, works very well.  It is only the critical cases that need to go to hospital. They have developed severe pneumonia, that compromise breathing making all activity difficult, and usually require ambulance transport. The number of these in Canada can be counted on your fingers.   The coronavirus numbers are starting to support the notion that it is a slightly more severe cold.  Testing has been reserved for severe cases, contacts, and the odd politician or wealthy celebrity.  Using this data, the death rate was thought to be anywhere from 4-9%. New data suggest that like cold viruses, the numbers of cases are much higher, recovering well and not getting tested.  The death rate of about 2% is probably limited to the severe and critical cases. As more testing is done, it keeps dropping and will probably be less than 1%.

    My colleagues at the CDC suggest that it is circulating in the population, i.e. pandemic. Like most new colds, between 40-70 % of people will acquire the virus, immunologically process it and move on within the next year.  The term prevention is misunderstood.  The current measures being employed are not aimed to erradicate it, but to "flatten the curve". This is an epidemiological term that refers to new case rate.  Basically, our medical resources are far more effective at treating a trickle of cases over a year than a deluge suddenly.   This is not being explained well enough, and causing a great deal of anxiety and hysteria.  In times gone by, whenever a village was being attacked by invaders, it was the young and healthy who went out to face them first and protect the sick and old.   We need to do the same thing.  Everytime one of us gets the virus and recovers, conveys protection to all those around them, and they can safely look after the others.  The current measures will not erradicate the virus, but will make management of the rare critical case more effective.

 

As of march 12,2020.(exact data hard to confirm)  4185 Canadians thought they had Covid19, and were tested.  Only 152 tested positive.  Only about 19 needed to be hospitalized. Most of them are recovering. Affects males and females equally, and mostly over 40 crowd.  The rest are at home or recovered. The other 4000 probably had a cold or flu.   ONE elderly nursing home patient with numerous other illnesses succumbed to it.  Testing is difficult and restricted, and officials assume that most cases are milder and recovering without testing.

Canadian Influenza data over last 5 mos. As in other years, this is the main health problem in the system currently, and burdening it.

28,871 laboratory confirmed cases of various A &B strains. Untested numbers far higher. Fewer B types and A more severe and affects mostly older folks.  2136 have been hospitalized, 265 needed ICU and 85 deaths so far, of which 5 are in pediatric age group. 87% have other health problems. Many strain types not in vaccine.  Older folks have greater rate of vaccine failure.

  Fear is clogging our health system, and the worry is that future response will be difficult.  When one world leader makes a poor decision, others are forced to react and the domino effect begins.   We have a national program that has been bean counting various flu cases for decades, in the continued hope that we can predict spontaneous mutation results.  One of my colleagues with vast experience during SARS cannot see any science behind border closing. If these measures do work, then we should quickly see a decline in flu cases and other infections and have a way to measure it without spending an extra penny.


COVID19 update March 10,2020

Tuesday, March 10, 2020

Covid19 update march 10, 2020.    

Peel Health Hot line 905-799-7700

You can also click on the right side of our home page for background information.

Testing is only limited to people meeting strict guidelines. People with severe symptoms are directed to go a screening center which are located at Trillium Hospital and Osler Hospital in Bramptom.

The health department strategy is to not issue protective gear to doctors in offices and walk in clinics, and no testing kits. 

Out of country Travellers are now asked to self quarantine for 14 days. This is catching many of our physicians and staff in a position where we cannot run offices.  We will continue to deal with urgent health care needs and provide phone support as much as we can.

People with respiratory illness are asked to not attend office and clinic setting where regular care is taking place.

Covid19 is a more severe form of the common cold and most healthy people recover.  Current strategy is to limit spread.

A perspective for context.

Each day 7452 people pass away in the USA

Heart disease and cancer account for about 48 percent

Accidents account for another 500 a day of which 110 are gun deaths.

Chronic lung diseases account for another 500 and stroke almost the same

There are about 250,000 new cases of the various flu strains DAILY

8200 people passed away from complications of the flu in the USA, but many had other conditions.


COVID19 update

Sunday, February 16, 2020

COVID 19 Update Feb 17, 2020

Feb 17, 2020 update.

 

The cornonavirus  outbreak had its name changed to COVID19.  There are over 70,000 thousand people affected mostly in China, and this is derived from very soft data.  There have been 1700 health care workers affected, including 6 doctors who are now deceased.  It is unkown whether they failed to use rigorous precautions, or whether they failed.   We do have a small snapshot of better data by looking at closed data.  Of 11, 208 closed cases, 85% fully recovered and 15% are in the critical or deceased category.  There are a lot of variables, cultural and otherwise.  China has been convinced to use diagnostic criteria similar to the west, which will change data.  Traditionally, they complete death certificates differently than in the west.  There is no effective cure other than our immune system as of yet.   Lab testing is available for those meeting strict criteria.  Simple masks probably afford some protection but no where close to complete. Those planning to travel in the next few months, should watch the situation, and check insurance coverages.  They may end up stranded or quarantined or even in a foreign hospital.   Influenza in Canada compares much less significantly.   COVID19 is a single virus and data is from the last 30 days.  In the last 5 months,  numerous different influenza viruses have caused about 27,000 infections altogether  in Canada, but only 65 deaths, many of whom had other co-morbities.   


Urgent After Hours Care is Available

Sunday, February 16, 2020

Please see below for the clinic schedule.  Urgent care is available after 5pm and on weekends.  Call

905-279-9322 for further directions and to receive phone or virtual advice.

As the Covid19 situation changes daily, doctors have been asked not to see respiratory illness in clinic. 

Tues March 31 - Dr. Graham

Tues March 31 - Dr. Talwar

Wed April 1 - Dr. Nasirzadeh

Thur April 2 - Dr. Silver

Thur -April 2 - Dr. Wong

Sat April 4 - Dr. Adam Chen (9 am)


2020 Novel Coronavirus

Tuesday, January 28, 2020

2020 Novel Coronavirus- update

Feb 5, 2020

     Laboratory confirmed cases 21,000.  Estimated untested cases 37000- 130,000.   This uses the same science we use with influenza virus, where we extrapolate confirmed cases into the community.  China has the densist world population, and this can be met with problems and inaccuracies.  There are 427 deaths with confirmed data, but numerous other deaths are currently not added into the total unless there is laboratory proof, so toll is higher. Only 711 fully recovered, so death rates, etc, cannot yet be accurately determined.  Doubling time is 6 days.  Flights from the epicenter have been largely stopped, Risk in our region is low at this time.  Problem is that illness looks similar to most other circulating viruses and only laboratory confirmation can tell the difference, which is impractical on a large scale.  Seems that mild cough is first symptom, with the fever appearing up to a week later.  Death rate is significant but looks like over 90 percent of people recover.  Males, elderly and infirm seem to make up the majority of confirmed cases.  We may be in a lull spot between new waves of spread.  Time will allow better prediction.  No vaccines yet or effective cure.  Keep your immune system healthy. China is being proactive and moving forward.  Much talk has been with regard to the new 1000 bed hospital built for severe coronavirus patients.  To put in perspective, China has 33,000 hospitals and could fit almost the entire population of Canada into a hospital bed at one time!  Half a billion patients went through this enormous system last year, which underscored how difficult it would be pick out one particular illness that resembles many others.

Jan 31 2020:  Positive Cases in every region of China: Estimates of 8-10,000 cases, over 300 deceased. First physician fatality reported.  Spread confirmed to at least 20 countries. 3 confirmed cases in Canada,  19 under investigation.  Canada- China flights suspended, Travel advisory against travelling to China.  Influenza A, continues to exert its annual effect in our catchment area.  WHO considers calling the situation a pandemic.  Economies will be severely effected which at this time is becoming a significant worry.Canadian officials are reveiwing and ensuring that adequate containment and response measures are ready to go if needed.

wed jan 29th:  the virus has spread to at least 16 countries. Global response varies and depends on the governement.  Hong Kong has closed borders,Russia has closed borders.  The decision to close a border is made by the government of the country. WHO continues to debate the usefullness of this measure.  Canada continues to welcome chinese travellers.  Overall numbers of infection and death continue to DOUBLE DAILY. Toronto area appears to be the hub at this time and has a case that appears to have spread locally, without any history of travel but contact with a traveller.   Infection seems to favour males in their fifties.  Children are affected much less, unlike influenza A, which continues to be our major viral problem currently.   The WHO feels that it is still early and continues to be in the outbreak stage.  It has not been contained as of yet and neither has the animal source been identified.  Efforts underway to develope a vaccine. A blood test is available but requires access through a special hotline and strict criteria must be met. 

 

Please see below for more info and how to screen and prevent.

 

 


2020 Novel Coronavirus

Monday, January 27, 2020

2020 Novel Coronavirus update:

You have probably heard by now of the new virus emerging in Wuhan China.  I would like to remind you that it is a work in progress. Information is being refined on a daily basis. We are in the middle of our flu season and there is a great deal of influenza A present in our community. In Wuhan China and surroundings,  there presently are approximately 100 million people being placed under restrictions. The risk of acquiring this virus is not considered great when you look at the entire country of Canada. However, we continue to welcome visitors by the thousands through our airports mainly Toronto and Vancouver. Just exactly how this will affect the situation appears to be a daily guess. Those visitors and travellers are appearing in our backyard and the situation will require more vigilance and care. Some countries have reacted by limiting travel from affected areas and closing their borders to these travellers while they examine the situation. There is a balance between losing commerce, tourist dollars, travel arrangements etc. However the cost to a publicly funded health care system can be staggering and possibly unsustainable as well.  It is a lesson that complicates the situation in any country without universal healthcare such as China. True numbers are difficult to obtain since many individuals do not have  the funds or desire or trust to approach the appropriate level of healthcare and screening.

More concerning is the recent observation that the virus can be transmitted by healthy carriers up to two weeks before showing any signs or symptoms. It takes close contact to get infected. The virus is not thought to be active or able to live on surfaces and temperatures below body level. This is an advantage. However, airlines recirculate their air in a closed cabin space  amongst hundreds of people for hours at a time. It is a favourable environment for incubation and transmission to occur.

We have learned a great deal already. The virus has been characterized and is similar to the SARS virus. Interestingly it is a distant cousin of the common cold. A blood test has been developed to confirm and diagnose those affected with it. Like influenza, there currently is no active treatment and there is work being done to produce vaccines.  The reality is that most people in our region who may panic and feel they have this virus will most likely be afflicted with influenza or  another respiratory virus. The problem is that you cannot tell the difference and need to await testing. Your own immune system is the key and paramount in helping you fight it. Remember, the viruses  do not exist to kill their host. They simply want a place to replicate and spread. It is the genetic mutation that becomes too overwhelming, but theoretically could put itself out of existence. The other problem is that many respiratory viruses mutate regularly to allow survival. Taking the above measures of handwashing, and extra vigilance helps a great deal.

Just to add some point of comparison. Influenza A is the bad influenza. It is composed of dozens  of different strains many of which are related and others not.. Unfortunately there is a active circulating strain that is not in the vaccine. However most people who get infected will recover quite nicely. The death rate is really very small and estimated at about 1 in a 1000 people if not less. By comparison, the atypical coronavirus has a death rate of between 5 to 15%. The exact numbers not yet known. This is a substantial difference on several orders of magnitude. As of today the atypical coronavirus has not affected the pediatric population to any great extent. Influenza a is quite active in this population.

Another question that we are  getting frequently is with regards to travel. As the situation is changing on a daily basis due to the numbers seem to be doubling every day, it is difficult  to render travel advice. It is impossible to determine which countries may choose to close their borders and impose travel restrictions. The approach is different around the world. Even China has a history of underestimating the numbers. Their population is so massive that it is a daunting task no matter who you are.  If you do travel, I suggest get up-to-date information from the Centre for disease control website and prepare for a possible response should the situation worsen very quickly.

stay tuned for reliable links and further updates as they come available: