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Registered Nurses' Association of Ontario      

Happy Sunday RNAO members!

A reminder of RNAO’s updated daily communications for this second month of the COVID-19 outbreak in Canada: You are receiving summary updates on Tuesday, Thursday, Saturday and Sunday – inclusive of Ontario’s Ministry of Health’s Emergency Operations Centre (EOC) Situational Report, and World Health Organization (WHO) Situational Report. In addition, you are receiving on Monday, Wednesday and Friday, longer updates such as the one you will receive tomorrow, which includes more details. To see previous updates visit RNAO updates and resources on COVID-19 for members and other health professionals. Feel free to share any and all updates with other health professionals at home or abroad.

MOH EOC Situational Report #43 here. The number of confirmed cases in Canada reported by EOC today is 63 cases. This includes a new case reported today in Ontario which bring our province to a cumulative total to 29 (this includes 4 resolved cases). EOC reports that in Ontario, at this time, we have 55 persons under investigation with lab results pending.

I am also including again and urge you to read the memo sent on Friday by our COVID-19 Command Centre Leadership.

Since we received the EOC report, media updates indicate two new cases in Alberta and one new case in Quebec – bringing the total in Canada to 66 (29 in Ontario, 4 in Quebec, 4 in Alberta and 27 in BC). We also have news that the Canadian Government will repatriate Canadians passengers aboard the Grand Princess cruise ship in the eastern seaboard of USA.

Public Health Ontario maintains an excellent resource site on materials on COVID-19. This is an essential resource for Ontario health providers; I encourage you to visit it. 

Another essential resource is Health Canada's website on COVID-19. It provides the best information capturing all of Canada. It contains an outbreak update, Canada's response to the virus, travel advice, symptoms and treatment, and resources for health professionals. This is, again, a vital resource for those following the COVID-19 outbreak in Canada.

The Public Health Agency of Canada has developed two new guidance documents for health system partners. The first, regarding community-based measures to mitigate the spread in Canada, and the second on informed decision making related to mass gatherings.

Situation Report 47 from WHO updates that worldwide there are 105,586 confirmed cases (3,656 new) and 3,584 deaths (98 new) in 101 countries (8 new). The vast majority of the new cases are outside China. There are 7,134 confirmed cases in South Korea (367 new). Other countries to note are Iran (with 5,823 cases, 1,076 new), Italy (with 5,883 confirmed cases, 1,247 new), Germany (with 795), France (with 706), Japan (with 455), Spain (with 430) and Switzerland (with 264). In all these countries the main form of transmission is local. The total number of confirmed cases aboard the Diamond Princess cruise ship is 696. Eight new countries (Bulgaria, Costa Rica, Faroe Islands, French Guiana, Maldives, Malta, Martinique, and Republic of Moldova) have reported cases of COVID-19 in the past 24 hours.

You can also find up-to-date global numbers in Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE.

WHO has issued a consolidated package of existing preparedness and response guidance for countries to enable them to slow and stop COVID-19 transmission and save lives. WHO is urging all countries to prepare for the potential arrival of COVID-19 by readying emergency response systems; increasing capacity to detect and care for patients; ensuring hospitals have the space, supplies and necessary personnel; and developing life-saving medical interventions. The page includes two modules:

1. Critical preparedness, readiness and response actions: WHO has defined four transmission scenarios for COVID-19: 1. Countries with no cases (No cases); 2. Countries with 1 or more cases, imported or locally detected (Sporadic cases); 3. Countries experiencing cases clusters in time, geographic location and/or common exposure (Clusters of cases); and 4. Countries experiencing larger outbreaks of local transmission (Community transmission). This document describes the preparedness, readiness and response actions for COVID-19 for each transmission scenario.

2. Responding to community spread of COVID-19: This document provides technical guidance for government authorities, health workers, and other key stakeholders to guide response to community spread. It will be updated as new information or technical guidance become available. For countries that are already preparing or responding, this document can also serve as a checklist to identify any remaining gaps.

Real-time training is critical for effective preparedness and response. WHO has several COVID-19 online resources for health professionals, decision-makers and the public in multiple languages. Please see the COVID-19 courses on OpenWHO here.

Infection prevention and control (IPC) is a major factor in preventive and mitigation measures for COVID-19. To ensure evidence-based quality guidance and prompt response to global demand for personal protective equipment (PPE), WHO has convened the IPC expert global network of specialists from around the world since the beginning of the outbreak. In consultation with this global IPC expert network, WHO has released three key IPC interim guidance materials. One of these is the Rational use of personal protective equipment (PPE) for COVID-19. This document summarizes WHO recommendations for the appropriate use of personal protective equipment (PPE) in health care and community settings, including the handling of cargo.

Critical: Please review the proper donning and doffing of PPE; guidelines can be found here.

Q&A: Similarities and differences – COVID-19 and influenza (from WHO here):

As the COVID-19 outbreak continues to evolve, comparisons have been drawn to influenza. Both cause respiratory disease, yet there are important differences between the two viruses and how they spread. This has important implications for the public health measures that can be implemented to respond to each virus.

Q. How are COVID-19 and influenza viruses similar?

Firstly, COVID-19 and influenza viruses have a similar disease presentation. That is, they both cause respiratory disease, which presents as a wide range of illness from asymptomatic or mild through to severe disease and death.

Secondly, both viruses are transmitted by contact, droplets and fomites. As a result, the same public health measures, such as hand hygiene and good respiratory etiquette (coughing into your elbow or into a tissue and immediately disposing of the tissue), are important actions all can take to prevent infection.

Q. How are COVID-19 and influenza viruses different?

The speed of transmission is an important point of difference between the two viruses. Influenza has a shorter median incubation period (the time from infection to appearance of symptoms) and a shorter serial interval (the time between successive cases) than COVID-19 virus. The serial interval for COVID-19 virus is estimated to be 5-6 days, while for influenza virus, the serial interval is 3 days. This means that influenza can spread faster than COVID-19.

Further, transmission in the first 3-5 days of illness, or potentially pre-symptomatic transmission –transmission of the virus before the appearance of symptoms – is a major driver of transmission for influenza. In contrast, while we are learning that there are people who can shed COVID-19 virus 24-48 hours prior to symptom onset, at present, this does not appear to be a major driver of transmission.

The reproductive number – the number of secondary infections generated from one infected individual – is understood to be between 2 and 2.5 for COVID-19 virus, higher than for influenza. However, estimates for both COVID-19 and influenza viruses are very context and time-specific, making direct comparisons more difficult.

Children are important drivers of influenza virus transmission in the community. For COVID-19 virus, initial data indicates that children are less affected than adults and that clinical attack rates in the 0-19 age group are low. Further preliminary data from household transmission studies in China suggest that children are infected from adults, rather than vice versa.

While the range of symptoms for the two viruses is similar, the fraction with severe disease appears to be different. For COVID-19, data to date suggest that 80% of infections are mild or asymptomatic, 15% are severe infection, requiring oxygen and 5% are critical infections, requiring ventilation. These fractions of severe and critical infection would be higher than what is observed for influenza infection.

Those most at risk for severe influenza infection are children, pregnant women, elderly, those with underlying chronic medical conditions and those who are immunosuppressed. For COVID-19, our current understanding is that older age and underlying conditions increase the risk for severe infection.

Mortality for COVID-19 appears higher than for influenza, especially seasonal influenza. While the true mortality of COVID-19 will take some time to fully understand, the data we have so far indicate that the crude mortality ratio (the number of reported deaths divided by the reported cases) is between 3-4%, the infection mortality rate (the number of reported deaths divided by the number of infections) will be lower. For seasonal influenza, mortality is usually well below 0.1%. However, mortality is to a large extent determined by access to and quality of health care.

Q. What medical interventions are available for COVID-19 and influenza viruses?

While there are a number of therapeutics currently in clinical trials in China and more than 20 vaccines in development for COVID-19, there are currently no licensed vaccines or therapeutics for COVID-19. In contrast, antivirals and vaccines are available for influenza. While the influenza vaccine is not effective against COVID-19 virus, it is highly recommended to get vaccinated each year to prevent influenza infection.

RNAO supports the Ontario government’s approach to 1) continue our public health and collective efforts to prevent, or at least delay, the spread, and 2) preparing all sectors for a possible large-scale spread so we are confident we can effectively respond. We are particularly stressing the importance of: 1) community care preparedness with off-site assessment centres and virtual care, 2) long-term care careful screening and preparedness, and 3) general public preparedness.

We urge you to continue to educate yourself and others on how to diminish the risk of transmission. You can see the WHO recommendations for prevention here.

Continue to keep us informed of questions and/or challenges of any kind, and especially shortages of PPE. Send these to me at dgrinspun@rnao.ca. You can also use the health provider hotline and website regarding questions about the outbreak, protocols, preparedness, and more. The toll free number is 1-866-212-2272, and the health provider website, updated regularly with useful resources, can be accessed here. An important reminder that the health provider website and the toll free number are for you – as a health professional – and not for members of the general public.

Ontario’s ministry’s public website on the COVID-19 exists to inform the general public – encourage your family and friends to access this public website. We also have information for the public on our website at www.rnao.ca which we update daily. The WHO has provided an excellent link for you to share with members of the public here.

I hope that those who are not working today had a chance to rest and relax. COVID-19 will likely be with us for a while, so it is important that we work hard to be ahead of the curve, and also take care of ourselves. The European Centre for Disease Prevention and Control states that “Unfortunately, it is not possible to predict how long the outbreak will last and how the epidemic will unfold. We are dealing with a new virus and therefore a lot of uncertainty remains. For instance, it is not known whether transmission… will naturally decrease during the northern hemisphere summer, as is observed for seasonal influenza.” Check this here.

RNAO’s COVID-19 Mantra: Let’s remain informed, calm and resolved – through collaboration we will tackle the COVID-19 challenge together And, apropos, togetherness, here is an important article for you to read and a tweet to retweet J

Doris Grinspun, RN,MSN, PhD, LLD(hon), Dr(hc), FAAN, O.ONT
Chief Executive Officer, RNAO 

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