Dear Colleagues: Welcome to our Saturday, July 10 report during this seventeenth month of COVID-19 in Ontario. You can find earlier update reports here, including thematic pieces in Doris’ COVID-19 Blog. And, for the many resources RNAO offers on COVID-19, please visit the COVID-19 Portal where you will also find RNAO media hits and releases on the pandemic here. Daily Situational Reports from Ontario's MOH EOC can be found here. As always, feel free to share this report and links with anyone interested. Scroll down for policy updates for all to act on & must join events.
The government announced today an earlier reopening of the province to step 3. The news did not come as a surprise given the successful vaccination rollout and decreased hospitalization rates. In several media interviews I expressed that although the five day advanced reopening is not a major concern, the lack of capacity restrictions in indoor activities is. For example, the requirement for a two meter distance between tables at a restaurant – without percentage limit of patrons – will be difficult to monitor and enforce. In the face of a dominating Delta variant and an even more aggressive Lambda variant (originating in Peru) in our doorsteps, having unvaccinated persons in large tables drinking and laughing could quickly lead to a fourth wave.
Fast-spreading variants will find the unvaccinated Ontarians. Government, and each of us, must drive vaccination rates even higher. The reason we will keep seeing worse and worse new variants is the dismal vaccination rate across most of world. Viruses run rampant and continue to mutate. The boomerang of vaccine nationalism in “have-to-countries” such as Canada is now hitting us back in the face. Countries such as Canada could have, and still can, do much, much more to help vaccination in disadvantaged parts of the world. Instead, they have allowed COVAX to fail. It feels like a breath of fresh air to see real initiative coming from President Joe Biden, but where is Canada?
Prolonged brain dysfunction in COVID-19 survivors: A pandemic in its own right?
This is an April 15, 2021 article by Chris Robinson, Assistant Professor of Neurology and Neurosurgery at the University of Florida. This article is republished from The Conversation under a Creative Commons license. Read the original article.
One in three survivors of COVID-19, those more commonly referred to as COVID-19 long-haulers, suffered from neurologic or psychiatric disability six months after infection, a recent landmark study of more than 200,000 post-COVID-19 patients showed.
Researchers looked at 236,379 British patients diagnosed with COVID-19 over six months, analyzing neurologic and psychiatric complications during that time period. They compared those individuals to others who had experienced similar respiratory illnesses that were not COVID-19.
They found a significant increase in several medical conditions among the COVID-19 group, including memory loss, nerve disorders, anxiety, depression, substance abuse and insomnia. Additionally, the symptoms were present among all age groups and in patients who were asymptomatic, isolating in home quarantine, and those admitted to hospitals.
The results of this study speak to the seriousness of long-term consequences of COVID-19 infection. Numerous reports of brain fog, post-traumatic stress disorder, heart disease, lung disease and gastrointestinal disease have peppered the media and puzzled scientists over the past 12 months, begging the question: What effect does COVID-19 have on the body long after the acute symptoms have resolved?
I am an assistant professor of neurology and neurosurgery and can’t help but wonder what we have learned from past experience with other viruses. One thing in particular stands out: COVID-19 consequences will be with us for quite some time.
Learning from history
Past virus outbreaks, such as the 1918 flu pandemic and the SARS epidemic of 2003, have provided examples of the challenges to expect with COVID-19. And, the long-term effects of other viral infections help provide insight.
Several other viruses, including a large majority of those that cause common upper and lower respiratory infections, have been shown to produce such chronic symptoms as anxiety, depression, memory problems and fatigue. Experts believe that these symptoms are likely due to long-term effects on the immune system. Viruses trick the body into producing a persistent inflammatory response resistant to treatment.
Myalgic encephalomyelitis, also known as chronic fatigue syndrome, is one such illness. Researchers believe this condition results from continuous activation of the immune system long after the initial infection has resolved.
In contrast to other viral infections, the COVID-19 survivors in the study reported persistent symptoms lasting more than six months, with no significant improvement over time. The abundance of psychiatric symptoms was also notable and likely attributable to both infection and pandemic-related experience.
These findings are leading researchers to hypothesize several mechanisms following acute COVID-19 infection that may lead to long-haul COVID-19. With the known historical context of chronic symptoms following other viruses, doctors and researchers may have a glimpse into the future of COVID-19 with the potential to create therapies to alleviate patients’ persistent symptoms.
When does COVID-19 really end?
COVID-19 is now known to be a disease that affects all organ systems, including the brain, lungs, heart, kidneys and intestines.
Several theories exist as to the cause of chronic, lingering symptoms. Hypotheses include direct organ damage from the virus, continual activation of the immune system after acute infection and persistent lasting virus particles that find safe harbor within the body.
To date, autopsy studies have not confirmed the presence or overabundance of COVID-19 particles in the brain, making the immune theories the most likely cause of brain dysfunction.
Some recovered COVID-19 patients detail significant improvement or resolution of long symptoms following inoculation with the COVID-19 vaccine. Others report improvement following a short course of steroids. The most plausible explanation for the direct effects of long COVID-19 on the brain are due to its body-wide connections and the fact that COVID-19 is a multi-organ disease.
These findings may point to a direct immune related cause of long COVID-19, though no real answers yet exist to define the true cause and duration of the disease.
The post-COVID-19 world
In February, the National Institutes of Health announced a new initiative to study long COVID-19, now collectively defined as Post-Acute Sequelae of SARS-CoV-2. The NIH created a fund of US$1.15 billion to study this new disease. The aims of the study include the cause of long-term symptoms, the number of people affected by the disease and vulnerabilities leading to long COVID-19.
In my view, public health officials should continue to be open and transparent when discussing the short- and long-term effects of COVID-19. Society as a whole needs the best information possible to understand its effects and resolve the problem.
COVID-19 remains and will continue to be one of the largest socioeconomic problems across the world as we begin to recognize the true long-term impacts of the disease. Both the scientific and research communities should continue to be diligent in the fight long after the acute infections are gone. It appears that the chronic effects of the disease will be with us for some time to come.
A Detailed Study of Patients with Long-Haul COVID
The following is an extract from a major study on long-haul COVID published in June 2021, done by Fair Health, an independent nonprofit that collects data for and manages the largest database of privately billed health insurance claims in the United States. Please go to the original study for references and citations.
Many patients recover from COVID-19 within a few weeks, but some exhibit persistent or new symptoms more than four weeks after first being diagnosed. These post-COVID conditions can last for months—even nine months, according to one study—and may be experienced by 10 to 30 percent of COVID-19 patients. The conditions can include, among others, fatigue, cognitive difficulties (sometimes called “brain fog”), headache, numbness /tingling, loss of smell or taste, dizziness, heart palpitations, chest pain, shortness of breath, cough, sore throat, joint or muscle pain, excessive sweating, insomnia, depression, anxiety and fever. Patients with COVID-19, after the first 30 days of illness, are at higher risk of death than people who have not had COVID-19.
Because this phenomenon is so new, much remains unknown about it. Even the name is unsettled: Patients with post-COVID conditions are variously referred to as having long-haul COVID, long COVID, post-COVID syndrome or post-acute sequelae of COVID-19. The causes of long-haul COVID are still unknown. Theories include persistent immune activation after the acute phase; initial damage from the virus, such as damage to nerve pathways, that is slow to heal; and persistent presence of low-level virus.
Many studies of long-haul COVID have been relatively small. The study thought to be the largest to date, which made use of US Department of Veterans Affairs national healthcare databases, involved 73,435 non-hospitalized patients with COVID-19 and 13,654 hospitalized patients with COVID-19, as well as approximately 5 million controls. Although the present study is a descriptive analysis without a control group, it includes more patients with COVID-19—a total of 1,959,982. To FAIR Health’s knowledge, this is the largest population of COVID-19 patients so far studied for post-COVID conditions.
To perform this analysis, FAIR Health drew on longitudinal data from its database of over 34 billion private healthcare claim records from 2002 to the present. The nation’s largest such repository, it is growing by over 2 billion claim records per year. All patients in the longitudinal dataset who had been diagnosed with COVID-19 from February to December 2020 were included, except for those with certain preexisting conditions (such as cancer and chronic kidney disease) that might have acted as confounders. The remaining 1,959,982 patients were studied for their case characteristics, such as age, gender and reaction to COVID-19 (i.e., asymptomatic, symptomatic, hospitalization, loss of taste or smell only). They were further studied for the prevalence of post-COVID conditions 30 days or more after their initial diagnosis with COVID-19. Their post-COVID conditions were analyzed, with the most common conditions identified. Particular attention was given to age and gender, mental health conditions and death.
Among the key findings:
• Of patients who had COVID-19, 23.2 percent had at least one post-COVID condition.
• Post-COVID conditions were found to a greater extent in patients who had more severe cases of COVID-19, but also in a substantial share of patients whose cases lacked symptoms. Of patients who were hospitalized with COVID-19, the percentage that had a post-COVID condition was 50 percent; of patients who were symptomatic but not hospitalized, 27.5 percent; and of patients who were asymptomatic, 19 percent.
• The five most common post-COVID conditions across all ages, in order from most to least common, were pain, breathing difficulties, hyperlipidemia, malaise and fatigue, and hypertension.
• The ranking of the most common post-COVID conditions varied by age group. For example, in the pediatric population (0-18), pain and breathing difficulties were the top two conditions, as in the all-ages cohort, but intestinal issues, rather than hyperlipidemia, were the third most common.
• Most of the post-COVID conditions that were evaluated were associated more with females than males. In the case of 12 conditions, however, males more commonly had the condition diagnosed than females. For example, of patients who had post-COVID cardiac inflammation, 52 percent were male and 48 percent female. By age, the largest share (25.4 percent) with this condition was found in a young cohort—individuals aged 19-29.
• Of the four mental health conditions evaluated as post-COVID conditions, anxiety was associated with the highest percentage of patients after COVID-19 in all age groups. Depression was second, adjustment disorders third and tic disorders fourth.
• The odds of death 30 days or more after initial diagnosis with COVID-19 were 46 times higher for patients who were hospitalized with COVID-19 and discharged than patients who had not been hospitalized. Of COVID-19 patients who were hospitalized and discharged, 0.5 percent died 30 days or more after their initial diagnosis.
• Among COVID-19 patients with preexisting conditions, intellectual disabilities were associated with the highest odds of death 30 days or more after initial COVID-19 diagnosis.
POLICY UPDATES FOR ALL TO ACT ON & MUST JOIN EVENTS – OPEN TO ALL
Webinar: COVID-19 Webinar Series
, 2:00pm - 4:00pm
Topic: The world after COVID-19
The pandemic has worsened existing global disparities. Wealthier nations are beginning to recover, while the poorest nations are still waiting to receive their first doses of the vaccine. Added to this is the projected drop in health human resources at home and abroad.
Join us on Monday, July 12 at 2 p.m. ET for a discussion with RNAO CEO Dr. Doris Grinspun who will share her worries about the future of health care and the world’s peoples, post pandemic. Will it be again the poorest of the poor who suffer the most? Will we start poaching nurses and other health providers from low resource countries? Who will pay the price and who will keep an eye on preventing further devastation?
Presenter: Doris Grinspun, RNAO CEO
July 12, 2021, 2 - 4 p.m. ET
August 9, 2021, 2 - 4 p.m. ET
Details coming soon.
Watch the 14 June past webinar:
Topic: Update on COVID-19 – Directions from the province and policy implications
We are now in the 16th month of COVID-19. Join us for an update on current issues related to this stage in the pandemic. RNAO CEO, Dr. Doris Grinspun outlines recent directions from the province, discusses the policy implications from RNAO’s perspective and has a conversation with participants.
Issues discussed include:
Presenter: Dr. Doris Grinspun, RNAO CEO
Watch and read about earlier webinars here.
NP Insider Webinar: Regulatory and Legal Issues for NPs in MAiD and Palliative Care
July 15, 2021 - 4:30 - 5:30PM
The NPIG Executive is pleased to invite NPIG members to our July NP Insider webinar, featuring three NPs in practice in palliative care and/or MAiD. Each will present their lived experiences, realities and struggles as well as answer all questions from NP Colleagues in a safe space.
When: Thursday, July 15, 2021 - 4:30 - 5:30PM
After registering, you will receive a confirmation email containing information about joining the meeting.
Continuing the Conversation: An Open Forum for Nurses
Aug 18, 2021, 2:30pm - 4:00pm
RNAO is aware nurses across Ontario – especially those working on the frontlines of COVID-19 – are experiencing tremendous levels of physical and emotional stress and burnout. We know this can affect your mental health and wellbeing at this challenging time and that you may have less time to devote to your own self care.
During these forums, RNAO facilitates open discussions and holds breakout sessions for participants to discuss themes identified in the previous forums, such as dealing with multiple losses, taking care of yourself, burnout and more.
All RNs, NPs, RPNs and nursing students – in all roles and sectors – are invited to participate. You may wish to share how things are going for you or you can simply join and listen in.
Visit our COVID-19 Portal for additional resources and information on psychosocial support.
Details and registration link coming soon.
Information about prior webinars can be found here.
MOH EOC Situational Report
We are posting each day the Daily Situational Reports from Ontario's MOH EOC at RNAO’s website. That way, you can access the Ministry’s guidance at any time.
For a more detailed Ontario epidemiological summary from Public Health Ontario, you can always go here.
Here is a segment from the last Situation Report #468 for July 9:
Staying in touch
Keeping in touch remains important as we face the pandemic and other challenges in Ontario, in Canada and elsewhere. Feeling that we are part of a community and that we have each other’s backs helps us get through these challenges, becoming better people in the process. We are eager to hear how we, at RNAO, can best support you. Send us your questions, comments, and challenges. Recommend ideas for articles and webinars. Write to me at email@example.com and copy my executive assistant, Peta-Gay (PG) Batten at firstname.lastname@example.org. RNAO’s Board of Directors and our entire staff want you to know: WE ARE HERE FOR YOU!
Thank you for being there for your community – everywhere and in all roles! Together, in solidarity, we are strong and resilient. In Canada we see hope at the end of this long pandemic tunnel. Vaccines arrive in large quantities and the rollout is speeding even more. We must not forget, however, about our privilege. Canada has purchased more vaccines than what it needs, while 9 out 10 countries have almost nothing. Like in other challenges we face, such as racism, Islamophobia, and other forms of discrimination, we are not safe until everyone is safe. Vaccines for all – literally for all, across the world – must guide policy in the upcoming 12 months. Let’s learn from the 16-month pandemic and take real action to build a better world.
To everyone – THANK YOU! Please take care of yourself and know that RNAO always stands by you!
Here’s one constant throughout the pandemic. The silver lining of COVID-19 has been to come together and work as one people for the good of all. Let’s join efforts to demand political leaders bring about #Vaccines4All!
Doris Grinspun, RN,MSN, PhD, LLD(hon), Dr(hc), FAAN, FCAN, O.ONT
RECENT BLOG ITEMS:
3 July - RNAO’s continuing media profile: The June report – go here
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26 June - Global herd immunity out of reach because of inequitable vaccine distribution – go here
26 June - Canada is virtue signalling while waffling on global access to COVID-19 vaccines – go here
20 June - Building your Twitter presence: Here are tips from RNAO – go here
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12 June - RNAO statement on the terrorist attack in London, Ontario – go here
12 June - Reducing the time interval for second dose after first AstraZeneca dose – go here
12 June - AstraZeneca second dose: Should I get the same vaccine or Mrna? – go here
5 June - RNAO’s continuing media profile: The May report – go here
5 June - RNAO supports Premier Ford's announcement on schools as risk is too high – go here
29 May - Vaccination passport apps could help society reopen – go here
29 May - Email updates highlight best new evidence about COVID-19 – go here
23 May – NPs speak about LTC during the COVID-19 Pandemic – go here
23 May – Three surveys on the impact of COVID-19 on Canadian nurses – go here
23 May – Exemption of nurses and other health-care workers from Bill 124 – go here
23 May – RNAO’s statement on the government’s phased-in re-opening plan – go here
23 May – Remembering Charlotte Noesgaard (1948-2021) – go here
15 May - Nursing Now Ontario Awards Ceremony – go here
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8 May - Nurses must be fully vaccinated immediately, RNAO demands – go here
8 May - A bill to support individuals with assistive devices for mental health – go here
8 May - Action alert: Ensure global vaccine access, prime minister! – go here
1 May - RNAO statement on the passing of RN Lorraine Gouveia – go here
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We have posted earlier ones in my blog here. I invite you to look.
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