NS COVID-19 Update for 23 April 2020

Daily brief

Dr. Robert Strang announced four additional COVID-19-related deaths on Thursday, three at the Northwood long-term-care facility (LTCF) in Halifax and one at the Harbourstone Enhanced Care Facility in Sydney. This brings total COVID-19-related deaths in the province to 16.

Shannex reported the death on its website today:

It saddens us to report that a resident from the Fishermen’s Cove neighbourhood at Harbourstone Enhanced Care has passed away. This resident had tested positive last week and was being cared for in our designated care/cohorting area at Harbourstone.

Dr. Robert Strang during the COVID-19 Update for 23 April 2020.

Dr. Robert Strang during the COVID-19 Update for 23 April 2020.

Dr. Strang also reported 55 new cases of COVID-19, bringing total confirmed cases in Nova Scotia to 827. Meanwhile 358 individuals are considered recovered from COVID-19, meaning active cases in the province now stand at 453.

Strang went into some detail about the 55 new cases saying the while eight Northwood residents and “a number of” staff have tested positive, the majority of the new cases were not connected to LTCs. Instead, 12-15 of them were in Dartmouth East, a known hot spot where Strang said they were looking to increase their testing capacity. “Sporadic” cases were detected in a number of communities in HRM, including Tantallon and Timberlea. He said that with the sporadic outbreaks their aggressive testing and identification of contacts has allowed them to  basically “lock the disease down.” Fortunately in these cases, he said, “we’re detecting people early on and isolating their contacts” so they’re not seeing any spread into the “broader community.”

Strang also noted that of the 921 tests completed by the QEII Health Sciences Centre’s microbiology lab on Wednesday, two-thirds came from the Central Health Zone (including HRM) while about 100 came from each of the other zones.

That said, he reiterated that there are cases of COVID-19 everywhere in the province and the death at Harbourstone in Cape Breton should serve as a reminder of that.

He also reiterated that we’re not out of the woods yet.

 

Numbers

Total new cases: 55

Total cases: 827

Total hospitalized: 10

Total in ICU: 4

Total recovered: 358

Total deaths: 16

Total long-term-care facilities (LTCF) affected: 10

LTCF residents: 158

LTCF staff: 79

Total positive and negative tests to date:  24,558

Age range of patients: under 10 to over 90

 

Re-opening

Strang pre-empted any questions about when the province would be re-opening and whether we would be following the example of “other provinces” who are considering re-opening in May (a list that includes Saskatchewan and PEI and possibly New Brunswick, which has now gone five days without a new COVID-19 case) by saying that he will be making decisions based on the epidemiology here in Nova Scotia, not in other provinces.

He said his team was currently at work on a plan which he hoped to bring to the premier and staff “for consideration” next week, but they will have to be comfortable with it before making it public. Strang reiterated that the goal would continue to be to protect the province’s most vulnerable people, including both seniors and frontline healthcare workers.

 

LTCs

Asked why Northwood is the only LTCF in the province to experience a big COVID-19 outbreak, Strang repeated what he’s said previously about the multiple, unintended introductions of the virus into the facility by unsuspecting and asymptomatic staff, some of whom had jobs that took them “widely throughout the facility.” Before the virus had even been identified at Northwood, he said, it had spread.

When the premier was asked later if the outbreak at Northwood could have been avoided if the system had “more staff and resources” ensuring fewer people had to work across multiple facilities or wings of the same facility,  Strang stepped in to clarify that at Northwood, the infected staffers were not working across the facility due to staff shortages. One, he said, was providing pastoral care, a role that required travel across the facility.

On the “flip side,” Strang said they haven’t seen the same circumstance at any of the province’s other LTC facilities where the cases tend to come from a single worker infecting “one or two” residents.

Asked why New Brunswick has reported no deaths in its LTC homes, Strang said all provinces were following the nationally developed guidance for LTCFs, an approach based on what they do each year for influenza, with some modifications. He said he had no explanation as to why New Brunswick has seen no deaths in its facilities, because most provinces with outbreaks in LTCFs have seen deaths.

The CBC’s Michael Gorman asked what measures could be taken, given the extent of the outbreak at Northwood, to stop further spread of the disease.

Strang said that they had instituted all the infection control “appropriate” for an LTC, which is a home to its residents, to try to minimize further spread. He said that the additional supports the province has brought in are allowing them to provide necessary care to those who test positive and that they are continuing to test residents and staff. In fact, he said testing of all residents should be finished today and testing of all staff tomorrow, although residents who test negative will be retested because some will likely test positive in a few days.

Strang also noted that of the 140 Northwood residents who have tested positive for COVID-19, the “vast majority” have suffered only mild symptoms and while he did not mean to “diminish the serious nature of COVID-19,” they were seeing that even the frail elderly “can battle it off with the appropriate care. In response to a later question, Strang offered more detail on what constitutes “appropriate care,” explaining it involves careful observation, intravenous hydration, encouraging patients to eat if possible, watching for signs of bacterial infection like pneumonia and, when necessary, providing oxygen.

Finally, a reporter — who said she understood speech pathologists and others were being called into Northwood to assist in various capacities — asked again if Strang was considering calling in the Canadian military to help. He said the incident management team on the ground in the facility has given no indication that this is necessary. Instead, he said, “We’re hearing the exact opposite,” that the necessary supports are in place and we have appropriate capacity.

 

NSGEU

The Chronicle Herald‘s John MacPhee said he’d heard Strang had met with the Nova Scotia Government and General Employees Union (NSGEU) today and wondered if he had addressed the union’s concerns over lack of personal protective equipment (PPE) and other issues (discussed in yesterday’s summary).

Strang replied:

No, I had no meeting with NSGEU today.

As a follow-up, MacPhee asked why, given that COVID-19 is known to affect more men than women, 59% of the cases in Nova Scotia are women?

Strang said it was down to two factors: women predominate in care facilities both as residents and as staff.

 

Courts

Apparently, the chief justice of the Nova Scotia Supreme Court, Deborah Smith, has complained that the courts are struggling to provide services, due to a lack of investment in IT over the past eight years (I couldn’t find this story online.)

Asked to comment on the chief justice’s concerns, the premier said Justice Minister Mark Furey will “continue to look at this” and “bring forward recommendations.” (I haven’t been keeping a running tally of how many things the justice minister is “looking at” but I think it’s starting to add up.)

 

Emergency Alert

Greg Mercer of the Globe and Mail joined today’s call to ask why the Emergency Alert wasn’t used during last weekend’s shootings. The premier thanked the EMO for “their work on the weekend” and “proactive approach” and said “I think we need to allow this process” meaning the RCMP investigation “to happen.” In “due time,” he said, “everyone will know why it wasn’t used. (If you haven’t read the Halifax Examiner’s timeline of events around the non-usage of the Emergency Alert system, I highly recommend it.)

Mercer then noted that the RCMP had opened a tip line for anyone with information about the case and asked if the premier could “say something” to people who might have information. (This was today’s oddest question, in my opinion.)

McNeil told people if they know something to call the tip line and to let the RCMP decide what is and is not valuable information, which is what the RCMP website says too:

“We’re looking for any information that could help with the investigation,” says Supt. Darren Campbell, Officer in Charge of Support Services for the Nova Scotia RCMP. “Anything you know – no matter how small or insignificant it might seem – could help us piece the puzzle together.”

The tip line can be reached at 902-720-5959 or toll-free at 1-833-570-0121. Police officers are answering both numbers. When you call, you may get voicemail, so please leave a detailed message along with your name and contact information. An investigator will get back to you. In order to gather and process the information as quickly as possible, we are asking people to use the tip line as their only point of contact to report information about the incidents.

The tip line was launched yesterday and announced at a news briefing to media. We’ve already gotten many tips and we thank the public for taking the time to reach out.

Remember: if you know something, please call and let our investigators decide the value of that information. That piece of information you have may be a turning point in the investigation.

 

Demographics

Bill Martin of Six Rivers News asked about what he saw as a “growing sense among younger people” that they don’t have to worry about the virus. He also requested separate stats by age, which the province actually does provide. Here are Thursday’s:

 

Nova Scotia COVID-19 cases by age as of 23 April 2020

Nova Scotia COVID-19 cases by age as of 23 April 2020

Strang said that if you look at this “from an international perspective,” you see that while people over 65 have higher risk of severe disease, the only group that appears to have minimal risk of severe disease is children: otherwise healthy young adults and teenagers have both been known to have severe symptoms.

Martin then asked why the MLA for Cumberland North (whom he did not name, but who is Elizabeth Smith-McCrossin) was able to announce that there had been “not a single case” of COVID-19 in Cumberland County, given that Strang has been “steadfast” in releasing numbers only by Health Zone.

The premier (to whom this question was directed) said information is shared each morning with MLAs, but the info given is the same info that “gets shared here every day.”

McNeil said he didn’t know where the MLA would be “getting her data from,” but the virus is “changing every day” and he would “strongly encourage every MLA not to give false hope to people anywhere in this province.”

Martin didn’t say where this announcement was made and I was unable to find it on social media.

 

Yay troops!

Okay, the funniest question today was from the reporter with the Aurora News which is apparently the newspaper for the Greenwood Airforce Base, who asked the premier:

Is it reassuring to know the the military has your back? They’re ready?

To which the premier gave the only answer he possibly could:

Yes, very grateful and reassured.

I hope an enterprising reporter with a retail trade magazine will call in and ask the same thing about cashiers.

 

Death counts

At the risk of seeming morbid, I thought I’d look into how deaths are classified as “COVID-19 related.” (One of the things I’m learning from the news these days is that my way of coping with awful things is to try to understand them so far as they can be understood which, with some things, isn’t very far.)

Consider this Part I. This is what I’ve been able to glean to date, but after certain eagle-eyed readers among you (you know who you are) read it and then ask me a series of pointed questions I can’t answer, I will know what I have to find out for Part II. Consider it a collaboration, of sorts.

The World Health Organization (WHO) has a classification system for diseases and health problems that is used by medical professionals to record cause of death. It’s called the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (IDC-10) and Canada uses a version (IDC-10-CA) “enhanced” by the Canadian Institute for Health Information (CIHI) to “meet Canadian morbidity data needs.” (As an example of a Canadian “enhancement,” it references our assisted death policies.)

On March 24, the WHO released Emergency IDC codes for deaths due to COVID-19 which look like this:

    • An emergency ICD-10 code of ‘U07.1 COVID-19, virus identified’ is assigned to a disease diagnosis of COVID-19 confirmed by laboratory testing.
    • An emergency ICD-10 code of ‘U07.2 COVID-19, virus not identified’ is assigned to a clinical or epidemiological diagnosis of COVID-19 where laboratory confirmation is inconclusive or not available.
    • Both U07.1 and U07.2 may be used for mortality coding as cause of death.

You will note that March 24 means the specific COVID-19 code was introduced weeks after the disease was declared a pandemic, which is one reason why epidemiologists, like this one who spoke with the Washington Post, think COVID-19 death tolls are incomplete:

“In the case of a new cause of death (like COVID-19), there are additional issues about incomplete capture of deaths due to the new cause, including a lack of an ICD-10 code,” said Keri N. Althoff, an epidemiologist and associate professor at the Johns Hopkins Bloomberg School of Public Health, referring to a WHO medical classification list. She noted the medical classification code for COVID-19 was only released the week of March 23. “There will likely be a lot of work on the ground and with statistical methods to estimating the number of deaths from COVID-19 prior to the release of the ICD-10 code.”

On April 11, the WHO released a definition for reporting COVID-19 deaths:

[A] COVID-19 death is defined for surveillance purposes as a death resulting from a clinically compatible illness in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g., trauma). There should be no period of complete recovery between the illness and death.

Here is the US Centers for Disease Control’s (CDC) guidance on determining whether the cause of death was COVID-19:

COVID-19 should be reported on the death certificate for all decedents where the disease caused or is assumed to have caused or contributed to death. [emphasis theirs] Certifiers should include as much detail as possible based on their knowledge of the case, medical records, laboratory testing, etc. If the decedent had other chronic conditions such as COPD or asthma that may have also contributed, these conditions can be reported..

Here in Nova Scotia, a spokesperson for the health department told me:

It is always the responsibility of the attending physician to determine the cause of death. With patients who die and are known to have COVID-19, it is often clear that the death is related to their COVID-19 infection and reported as such. However, there may be cases where a person is known to be positive for the virus that causes COVID-19, but the cause of death is not related to their infection and would not be reported as a COVID-19 death.

There is a further step in this province:

A regional Medical Officer of Health reviews any death of an individual who is known to be positive for the virus that causes COVID-19 and if necessary, will discuss the cause of death with the attending physician to determine if the death was COVID-19 related or not. If necessary, COVID-19 testing on the body can be done.

But when it comes to patients with underlying causes (or “comorbidities”), determining the cause of death is open to a certain amount of interpretation. As Tom Avril wrote earlier this month in the Philadelphia Inquirer:

A subtler issue is what to do when the patient has other serious medical conditions. If the person suffered from chronic lung disease, then became infected with the virus and died of pneumonia, the immediate or primary cause would be pneumonia as a result of COVID-19. The lung disease would be listed as a contributing condition, said Sally S. Aiken, president of the National Association of Medical Examiners.

The reason we need to be as accurate as possible in determining COVID-19 deaths is that the information will help us understand how lethal the disease actually is. Mind you, determining that also means getting a better handle than we currently have on how many people have (or had) the disease, because the case fatality rate (how many people diagnosed with COVID-19 ultimately died of it) and the infection fatality rate (how many people who contracted COVID-19 ultimately died of it) are likely to be very different numbers.

Adding to the data collection difficulties, different jurisdictions use different definitions of just what constitutes a COVID-19 death. Italy, for example, used a very broad definition, counting any victims who had tested positive “even if others illnesses were at fault,” reports Avril. Some think this may have contributed to Italy’s high case fatality rates (13.2% as of April 16).

On the other hand, Germany, which has a relatively low case fatality rate, also uses a broad definition of what constitutes a COVID-19 death. This makes researchers suspect the difference in fatality rates is down to something else (not demographics, though, apparently the median age of the German population is a bit higher than Italy’s). The suspicion is that broad testing combined with a disproportionate number of young people contracting the virus has kept Germany’s case fatality rate relatively low (2.9% as of April 16).

And that’s as far as I’ve got with my research to date.

 

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