April 14 Town Hall Q&A: Part One
On April 14 the Medical Staff Association opened up its weekly meeting as a Town Hall to give all PHC staff and researchers the opportunity to hear a Public Health update and to participate in a Q&A. On hand to answer questions were Patricia Daly, Vice-President, Public Health and Chief Medical Health Officer, Vancouver Coastal Health and Fiona Dalton, CEO and President of Providence Health Care.
Below are questions that were answered during the session (Part One). Watch for Part Two coming soon (questions we didn’t have time to address). Thank you to all you attended.
Testing & Tracing
- How many staff have tested positive at Providence Health?
- We have approximately 8,000 staff and medical staff at PHC. Between March 20 and April 13, we tested 525 (or 7%) staff at our MSJ and SPH Emergency Departments and the testing site at 33rd and Heather. (We do not have the numbers for PHC staff who have gone to other testing sites in Fraser and VCH). Of those staff who were tested, fewer than 20 have tested positive. That’s about a 3% positivity rate, which correlates with all the other figures we’ve seen. The large majority of these individuals either have recovered or are recovering. Clearly there are confidentiality issues, but every member of staff has been followed up, been supported and in terms of contact tracing we’ve tried to establish if they became positive through the community or at work.
- Alberta just released guidance to test everyone with symptoms. Why is BC not doing the same? (37:30)
Updated: The latest provincial testing guidelines for BC were released on May 11, 2020. You can find them here.
Guidelines for COVID-19 testing in BC are updated based on the changing epidemiology, testing capacity, and our evolving understanding of test sensitivity in clinical settings. At this time, it is critical to ensure timely identification of new infections and their contacts to prevent community spread of COVID-19. Anyone with symptoms, however mild, may be tested for COVID-19. Individuals in the following groups should be prioritized for testing:
a. Residents and staff of long-term care facilities
b. Individuals requiring admission to hospital or likely to be admitted, such as pregnant individuals near-term, patients on hemodialysis, or cancer patients receiving radiation or chemotherapy.
c. Healthcare workers
d. Individuals with a higher probability of being infected with COVID-19 such as contacts of a known case of COVID-19 and travellers just returned to Canada
e. Residents of remote, isolated, or Indigenous communities
f. People living in congregate settings such as work-camps, correctional facilities, shelters, group homes, assisted living and seniors’ residences
g. People who are homeless or have unstable housing
h. Essential service providers, such as first responders
- When will the COVID-19 antibody tests be available and will they useful? (36:38)
- We are hoping to do some validation of the antibody test and are working with BCCDC. We don’t know when the tests will be broadly available. You may have heard other jurisdictions talk about when you start to lift public health measures that it can be useful to know who might be serologically positive, like health care workers and other workers returning to work. We don’t know for certain yet if the serological test can tell us if people are immune and for how long. The experts say with other coronaviruses, it’s likely if you are serologically positive you may have long term immunity, but we don’t know that yet. Some of this research is underway but we don’t yet know when we will have the test available or how broadly it might be available. We are waiting for our provincial laboratory to provide more information on this.
- While we seem to be happy with the number of cases, isn’t it a false metric because we aren’t testing everyone? Why does BC have restrictive testing policy vs that of WHO, Alberta, Ontario and successful regions (e.g. S. Korea, HK, NZ) (41:37)
Updated: We did change our province-wide testing criteria on April 8 and updated it again on May 11. Any clinician can test anyone showing symptoms, however mild. We are following testing guidance that the WHO has put in place, depending on the appropriate stage of the epidemic. Guidelines for COVID-19 testing in BC are updated based on the changing epidemiology, testing capacity, and our evolving understanding of test sensitivity in clinical settings. Now that we have had a leveling off of cases, we have opened up testing so clinicians can order a test for anyone with symptoms. We still don’t recommend testing for completely asymptomatic people.
The data we are very confident about is the hospitalization data and the number of admissions to the ICU. Fraser Health has had fewer total positives than Vancouver Coastal but more hospitalized cases, and that’s because they didn’t have as much access to testing that we did in VCH/PHC primarily, thanks to St. Paul’s laboratory.
The hospitalization data is the real number of people with severe disease and that has been flat and falling for a few weeks now.
- With several health authorities generating guidance statements would you recommend a more unified Provincial directive? (42:56)
- As much as possible, we try to align with the provincial guidance, which is found on the BCCDC provincial website. Almost every night, we have a Public Health call with BCCDC, the province and all the health authorities to optimize alignment. We even delayed getting our new April 8 testing criteria out because we wanted it approved provincially. It’s the same guidance on the BCCDC website.
However, we will establish our own guidance if we are dealing with a situation where we don’t yet have provincial guidance. For example, for some of our long term care strategies we developed our own guidelines first, because there were no provincial guidelines. But now there are provincial, and even national guidelines coming out. We did the first order restricting staff in long term care, and then the province followed. Because we have some cases in group homes, we have provided guidance to those organizations, and now there is provincial guidance.
- How is contact tracing done and why has VCH/PHC not put in a request to have medical students joint contact tracing teams? (45:53 - 48:06)
We have talked to our colleagues around the country about their contact tracing strategy. VCH set up a unique structure in Public Health for contact tracing using almost all of our Public Health staff (we put on hold most of our routine Public Health activities apart from critical work, such as immunizing young infants and children, and follow up of new babies). We’ve redeployed all of our environmental health officers, for example, many of whom were involved in communicable disease follow-up prior to COVID-19. Although Fraser Health may use medical students, we have nurses, health inspectors, and others included in our contact tracing teams. In Vancouver Coastal we use a pod structure, which is a group of about six staff. Every pod has at least one nurse, and may have other nurses, a Public Health inspector, medical students or residents. Each pod is led by a physician.
We have 11 pods now, all reporting up to a medical health officer who may have several pods working under them.
The reason we like this approach is the pods gain experience in contact tracing and if we need more capacity we split a pod and bring in three new people. This means new pods have three experienced people and three new people. We think our approach can be scaled up easily because, like an amoeba, the pods can be split into two and we can create new pods when we need to.
Other Public Health units across the country have chosen to use medical students, but we considered that the school season ends in June.
- How do you follow up with health care staff when there has been a positive result on the unit? (50:21/47:58)
When we get a notification we have a positive exposure in the workplace, we reach out to the unit managers that are impacted and ask for staff lists for the period of the exposure, including all allied health and contract staff (security, housekeeping, food services, etc). We provide the list to the provincial Workplace Healthcare Centre who does a wide reach of follow up on everyone.
We do the physicians separately and internally. Residents are covered under the provincial Workplace Healthcare Centre because they are considered employees of Vancouver Coastal Health. We reach out to the physician lead indicating the time of exposure, the department, and which physicians were impacted. Then we reach out to the physicians to ask if they have any symptoms, and share the exposure and the criteria.
- What if I test positive, what would be the process? Who gets notified?
The information flow for contact tracing is on the COVID-19 website under the Resource section. We use Cerner as well.
If you have gone to one of our PHC testing sites and test positive, notification is sent to Public Health, Occupational Health and Safety, and to IPAC. We check if it’s a PHC employee or a physician.
Public Health does the first interview because there is a standard WHO questionnaire used to interview every single case, to determine the infectious period, and to identify the contacts. Public Health also uses a national criteria on ‘who is a contact’.
Public Health asks Occupational Health & Safety and IPAC to be involved to help trace where the person went and who were the staff working in that area during the period. When we get alerted to an exposure, it indicates the unit and dates of exposure. We look 48 hours ahead of when the person was symptomatic (the infectious period) and let the manager of the department know there has been a positive exposure in their department and over what period of time. We don’t indicate whether it was a patient or staff, but we do ask for a list of people who were working at that time and share this with Public Health. Within 24 hours we have the notification out and are working with everybody impacted.
Based on our followup, we believe most health care workers acquired COVID-19 in the community.
It's very important to wear PPE while at work. The last several exposures have been ‘non-events’ - the patient came in masked, and was masked at all times, and our staff were masked at all times. The proper use of PPE dramatically reduces the risk of exposing others.
In long term care, where staff have been the source of exposure to vulnerable patients, the use of PPE means there is less opportunity for staff with mild symptoms to expose COVID-19 to residents. The same is true for acute care. PPE is not just about protecting you, but also protecting patients and colleagues.
- What is the turnaround time for contact tracing from time of receipt of lab result to implementing quarantine to those exposed? (56:54/54:43)
The turnaround time for contact tracing varies. The Public Health team works 24/7. We first need to interview the person to determine their contacts and track the contacts down. For most patients, if the doctor has given them correct guidance and if they’ve been tested, the patient should have been told to self-isolate. They may be at home awaiting the results. Or they may be in the hospital, possibly too sick to be interviewed, in which case we interview the family to try to determine when symptoms started.
The initial interview by Public Health is usually done in less than 24 hours of getting the case. We will identify the contacts and follow up by phone usually within 24 hours.
There have been some exposures where VCH couldn’t identify all the contacts. For example, the dental conference in Vancouver resulted in a positive case, and after interviewing the person, VCH realized there was such a broad exposure among people they couldn’t individually identify everyone, so a press release was issued to advise anyone at that conference they could have been exposed and to self-isolate. Those incidents have become fewer and fewer because there are no more mass gatherings, many workplaces are closed, and people are physically distancing and self-isolating if they are symptomatic, all of which has helped to reduce the number of contacts exposed.
- When can COVID-19 positive health care workers come back go work? Do they need a negative test? (1:01: 22)
- We have the same criteria for health care workers as we do for non-health care workers with mild disease. Health care workers can return to work 10 days after the onset of symptoms, if they are symptom-free and free of fever for 72 hours, other than a residual cough.
- With expanded out-patient testing criteria (incl. clinician judgement) what concurrent increment in testing sites has occurred? Where is a central list of sites? (1:09:52)
The list of testing sites in the province is on the BCCDC website and available through 811. None of them are at capacity. We did see a bump, during flu season when lots of people (both staff and community) who had fever and cough were getting tested. We had a 2-3% positivity rate at that time. Now that flu season is over, and we have fewer people with respiratory illness in the community, that positivity rate hasn’t gone up that much. There is not a lot of COVID-19 out there, but there is lots of testing capacity.
All of our testing sites could test more people. We are now focused on getting testing materials to certain populations we might be concerned about, like the Downtown Eastside, and rural, remote, and indigenous communities to ensure we can do more testing in these populations.
- Is the expansion of testing going to be uniform across the different regions? (1:08:48)
There was a period of time when we were focusing only on certain populations because we had limited testing capacity, but that changed province-wide on April 8. The new guidelines, which are on the BCCDC website, advise clinicians they can order a test for anyone they are concerned about. There are some specific populations we want to focus on for a greater degree of testing, which includes anyone living in congregate settings (such as shelters, group homes, and correctional facilities), rural, remote, and indigenous communities, long term care homes, health care workers, and anyone hospitalized. We now have testing capacity around the province.
The new guidelines were sent to every family doctor in the province, and every urgent care center. All health authorities also sent out similar physician bulletins in their region. However, it can take a couple of weeks to socialize this new information with physicians.
The guidance is still that we do not test asymptomatic people because the test is not reliable for them.
- Will community workers testing people and working with COVID-19 patients be provided with PPE and will they be supported with training? (1:16:19)
Yes. Anyone taking a test, which is the nasopharyngeal swab, should be wearing appropriate PPE, that is: mask, eye protection, gloves and gown. The health authority provides the PPE free of cost. This includes PHC-affliliated GPs.
At this time, our principle is to provide free PPE to direct care workers in order to protect our clients and patients whether they are receiving care in a private nursing organization or private long term care facility. We’re doing this, because we consider these clients and patients as our citizens.
- If a physician believes a patient needs to be tested and their clinic doesn’t have the set up to do so, where do they send the patient? 1:20:39
- Physicians can send the patients/clients to a UPCC. We have communicated the new testing guidelines to all the UPCCs including using clinical judgement to test anyone who has symptoms. If physicians have sent people to a UPCC and their clients have been rejected, that likely happened before the new guidelines were in place. Physicians can call 811 for a list of all testing sites in the province, or find it posted here. If you send someone for testing, you can call ahead to ensure they are accepted at the testing site.
- Are we telling other symptomatic essential workers to self isolate instead of getting tested? (1:28:28)
- Updated: At this time, it is critical to ensure timely identification of new infections and their contacts to prevent community spread of COVID-19. Anyone with symptoms, however mild, may be tested for COVID-19. Individuals, including health care workers and essential service providers, such as first responders should be prioritized for testing. The latest provincial testing guidelines for BC were released on May 11, 2020. You can find them here.
- How can we sure we don’t go back to the same ‘normal’ after the pandemic?
We in B.C. have earned the right to think about this, through all the hard work within PHC/VCH organization, the other health authorities, Public Health, government and through the general public who have taken social distancing and hand hygiene seriously. In Paris, London and New York, they aren’t getting a chance to think this way. Our world still could be very different as we’re still in the midst of this and we need to still take care of the very sick and COVID-19 patients.
But we can acknowledge for many of us, there is also space to think about the future. We are conscious of the patients in pain and disability waiting for surgery. And we need to get back to that normal. But there are also lots of other things where ‘getting back to normal’ doesn’t seem so attractive. The obvious one is virtual health. All those patients we can talk to by phone or Skype or Zoom, let’s not go back to making them all come into the hospital.
What would we really like to keep? On March 11, we thought restricting long term care staff to just one site was impossible. Less than a week later, Dr. Daly, quite rightly, issued an order that said we had to do just that. In a few days, we had done it and was subsequently copied by the rest of the province. That’s just one example we’ve seen over the past few weeks where the usual rules don’t apply and that we can do the impossible. As we all begin to imagine what a new normal might look like, and accepting this new normal might include a lot more testing, social distancing, and managing ongoing outbreaks of this horrible disease, please also let’s keep making the spirit of making the impossible possible.
- What limitations does Public Health face implementing an ideal containment approach and how can MSA/PHC assist? (46:29 /44:08)
Some countries that have really been successful had real control over their borders to identify any cases arriving among travelers, which we did quite successfully for a period here in BC. Our very fluid southern border with Washington state was challenging for us because we weren’t identifying and testing those who just traveled over the border from Washington.
We need good access to testing and we need clinicians to do testing. We want to identify as many positive cases as we can. We are now recommending anyone with symptoms, returning travelers even, get tested. Medical staff can help us by testing anybody they suspect may have COVID-19. We have capacity now in Public Health to follow up on all those positive cases and their contacts. VCH is implementing technology through the Telus home health monitoring system to support this, which may be particularly useful for contacts.
PHC/MSA Medical staff can help us with active testing. The work PHC is doing in infection control and workplace health to identify contacts among PHC staff and within hospital settings is really valuable. Vancouver Coastal relies on working with Providence in partnership to do that.
- Why is there no fine for those breaking social distancing? (59:13)
- There is no Public Health Order for social distancing. It is only a recommendation, or general guideline. It is not a rule and there are no fines.
The Public Health Orders we have in place in the province pertain to:
- public gatherings of 50 people or more
- bars closures
- restaurants operating take out only versus dine in
- personal service establishments closures, such as spas and hair dressers
- travelers required to self-isolate for 14 days
Public Health understands social/physical distancing is not always practical, for example in a daycare setting, or when responding to an overdose in the Downtown Eastside. There are some places where essential workers have to work closer than 2m apart.
Physical distancing is not the most important thing a person can do to prevent spreading COVID-19 in the community - hand washing is. Additionally, you can avoid exposing others by staying home if you are sick, coughing into your sleeve, and of course social/physical distancing.
- What’s the objective indicator that we can relax restrictions? (1:05:19)
- There is likely not just one indicator telling us we can relax restrictions.
Then you have to ensure you have broad access to testing, which we think we do now in B.C.
You need the ability to get back into the containment mode, similar to when we had those first few cases of returning travellers. You need to be able to identify every case and isolate them immediately, and identify and isolate their contacts. We think we have this capacity now in BC.
We are working with experts at the BCCDC and at UBC to consider what measures we could start to lift that would have the least rebound, but that would address some of the unintended consequences we have had from restrictions. We’ve talked about how we may reopen schools and certain businesses. We aren’t at that point yet, but those are the kinds of discussions we are having. We are working with guidance from other experts around the world too, who are having these same discussions now that they too have started to see their curves flattening.
- What are the specific plans to contain the second and more waves? (1:04:34)
We hope we don’t get large second and third waves. We think we may get a little increase as we gradually release restrictions.
We’ve been told it’s very hard to lift all restrictions and then try to reimpose them if another outbreak occurs. At the same time, we don’t want to concern people by saying we’ll be under all these restrictions until we have a vaccine. There will be some strategies we can use to try to stop the spread until there is a vaccine or effective treatment. We are following the vaccine trials with great interest,
There are also modellers and experts who believe if you do flatten the curve you can start to lift some of the measures we’ve put in place, slowly and with careful monitoring. For example, China is now focusing on containing travelers coming to their community.
We will have some Public Health measures in place until we have a vaccine or treatment, and that is still quite a few months away.
- Given the relatively small numbers of cases in BC, do you feel it was warranted to shut down society? Won't this actually have much worse consequences? (59:13)
Public Health monitors the unintended consequences of some of the measures it puts in place. For example, negative impacts can include cancelling elective surgeries, or fewer people coming to the emergency, resulting in physicians seeing quite sick people, or home support clients cancelling their support because they are worried about having a health care worker in their home. We’ve also had spikes in overdose deaths in the Downtown Eastside because people with substance use issues are worried about going to overdose prevention sites, which is worrying because their bigger risk is an overdose death.
Some other countries with COVID-19 outbreaks have already identified death rates went up, not only from COVID-19, but from other health care conditions because people didn’t access the other health care they needed.
As the curve starts to flatten, we don’t want to lift measures too quickly because we don’t want to see a large rebound in COVID-19 cases and then have to reimpose restrictions. We have to balance the unintended consequences.
- Is Public Health adequately funded and resourced during the COVID-19 pandemic?
- Public Health has the support from our health authority and CEOs. In our region, the message from VCH and PHC CEOs, and both our board chairs is whatever resources Public Health needs, they can have. Everyone in Public Health doing case and contact follow-up is being paid and seconded staff have been added to help with the work. If we need more staff, we can continue to second them, whether they are nurses or other staff. In the community, there is staff and capacity to do the work, because some other programs are not operating.
- How are we supporting SROs with instruction on what to do when a resident is tested for COVID-19? (1:23:00)
- There are weekly calls with all the SRO operators to provide them with guidance and VCH has a medical officer who can answer all their questions. VCH works closely with BC Housing, and has an outreach team that can provide training and education for SRO staff as needed. We provide information on the outreach team at PHC emergency departments. All the SROs now should have the information so they know who to call if they have someone with symptoms.
- What is the current evidence of recurrence or reinfection rates for COVID-19? (37:59)
We haven’t heard anything about people being reinfected. We’ve had some cases where people test positive, then negative, then positive again but this doesn’t necessarily mean it’s a recurrence. We have to be very cautious about the test results. If you swab the virus it's highly sensitive in identifying, especially with the nasopharyngeal test, but if you don’t pick up cells that have the virus you may get a false negative result. It’s quite possible this can happen more often in people with lower respiratory tract disease - that the nasopharyngeal swab may be negative. That’s why it’s suggested you get a sputum swab or a lower respiratory tract swab.
We’ve had cases, especially in those that have more severe disease, where they test positive, then negative, then positive. We don’t think that’s reinfection. It may just be that they still have evidence of the virus. We have to be cautious that our tests also don’t necessarily mean it’s viable virus. We haven’t had any cases here which we think are reinfections.
In the media there are references from South Korea of patients who come back positive again and they are looking at those specific cases to see if it is truly reinfection, or the same virus being detected through genetic testing, but not a viable virus.
Initially, our criteria for releasing patients from isolation were two negative tests 24 hours apart, and in a number of our early cases with people with mild symptoms recovering at home, it was weeks and weeks afterward and they were still testing positive, but it doesn’t necessarily mean the virus was viable.
For people with mild disease recovering in the community, if they have no symptoms at 10 days other than a dry cough and have been without fever for 72 hours, we release them from isolation, and that includes health care workers, without repeating the test because there is very good data from other countries those people are no longer contagious to others.
We’ve done a literature review to see how long after more severe cases the virus is viable, and the maximum is 37 days. So COVID-19 can go on for quite a long time in severe cases but the lab test could be positive for even longer. For hospitalized cases, we follow up with them upon discharge and wait until they have complete resolution of symptoms before we release them from isolation.
- What is the most recent evidence and guidance about the infectivity period after COVID-19 recovery, and does it differ between mild/severe cases? (57:36)
For mild cases, we follow guidance from the Public Health Agency of Canada. If the person has mild symptoms and is recovering in the community, it’s 10 days after the onset of symptoms. If they have no symptoms apart from chronic cough and they’ve had no fever for 72 hours, they are released from isolation. Some other countries, including the U.S. and U.K., use seven days. We use 10 days to ensure they truly aren’t contagious to others, and we feel quite confident in that.
It is different for the severe cases, as those are usually hospitalized cases, and many are in isolation. If the person is still symptomatic at the end of 10 days, we continue to monitor them, and won’t release them from isolation until they are completely free from symptoms, apart from a residual cough. Public Health wants to be notified when they are released to the community and will continue to follow up with the patient, and continue to have them isolated until their symptoms have resolved other than the residual cough.
- Are all deaths being coded as COVID-19 and not an aggregation of pre-existing conditions? (1:08:36)
If someone dies and they have COVID-19, we are counting those as COVID-19 deaths, even though realistically some people, especially in long term care facilities, were already near the end of life or were palliative. But if they were positive for COVID-19, they are coded as COVID-19.
There have been a small number of deaths in the community identified by the coroner as COVID-19 positive post-mortem, although they did not test positive or were not identified as COVID-19 prior to death.
- When a death occurs in the Downtown Eastside or a long term care facility or acute care, are we doing a limited autopsy if COVID-19 is a possibility? (1:23:56)
In long term care we have tested some people after death, and we are following up on every death. In long term care we have very low thresholds for testing people now.
If someone dies in the community, that’s a coroner's case, and Public Health is not involved. There have been a small number of these cases. For example, one was a known positive patient who died in the community and the coroner investigated. Another was a dentist in the community, who attended the Pacific Dental Conference, self-isolated, never tested positive and later died. The coroner tested this person after death and the person was found to be positive. The coroner is doing testing if they identify deaths in the community that may be COVID-19, unless the death is obviously due to another cause.
If you need to reach PHC’s Infection Prevention and Control Team (IPAC), please call local 69357. Do not contact individual IPAC team members.