[Dr. Dina News] Adults In Pediatric Care

This is my 25th weekly COVID-19 update. Subscribe to Dr. Dina

Hello friends,

I hope you and your loved ones are healthy and safe.

Sadly, this isn’t an uplifting COVID update, but I hope it is an educational one.

As we do each week, we will review the bad news, followed by the good news, my most commonly asked question of the week, and my silver lining.

What is the bad news?

Lots of bad news, I’m afraid.

Canada had reported more than 1.1 million cases of COVID-19, with over 23,500 deaths.

Over 140 MILLION cases of COVID-19 have been reported worldwide, which is likely a considerable underestimate. 3 MILLION people have died from COVID.

I have been outspoken about the humanitarian crisis that is burdening Brazil right now. Endless cases of COVID-19, so much death and devastation. Many of us are worried about additional dangerous variants of concern that may be brewing in the Petrie dish of many people with COVID infection. And now, Brazil’s hospitals are running out of medicine needed to sedate COVID-19 patients. There are reports of seriously ill patients being tied down and intubated without effective sedatives. This is the stuff of nightmares. My heart aches for these people and their families.

India is seeing over 200,000 NEW COVID cases a DAY. There is a significant strain on an already fragile healthcare system.

In Ontario, COVID-19 cases, hospitalizations, and ICU occupancy are at their highest levels since March 2020. Variants of concern continue to rise quickly. ICUs are filled, which compromises care for all patients due to capacity and healthcare provider shortages. Surgeries and non-emergency procedures will continue to be bumped.

As COVID-19 increases and hospitalizations intensify, and with an expected surge in healthcare demand, Ontario is looking for solutions to efficiently deploy physicians to healthcare facilities across Ontario. As we saw in the U.S., physicians may be moved to areas outside their specialties to work in ICUs, emergency rooms, or medicine wards.

Already pediatric emergency medicine colleagues across the country are being asked to help in adult ICUs. There are too many adult patients admitted and not enough adult ICU doctors to care for them. We need to remedy this deficit. Plus, fill the void of nurses, respiratory therapists, porters, phlebotomists, janitorial staff, administrators, and so many others. Increased admissions aren’t just a challenge of physical space, but health care providers and team members as well.

The Hospital for Sick Children and the Children’s Hospital of Eastern Ontario are now taking care of adult ICU patients. In the GTA, all pediatric patients requiring inpatient care are being transferred to SickKids. All of them. Why? Other hospitals are overwhelmed with adult COVID patients.

The Ontario Science Advisory Table shared new modelling that suggests we could see more than 30,000 daily NEW cases of COVID-19 by the end of May. They predict the number of COVID-19 patients in the province’s ICUs could reach 800 to 1,000 in the next two to three weeks. This is serious.

The Advisory Table ran many scenarios and found that we need a six-week stay-at-home order AND at least 100,000 vaccines given a day in Ontario to flatten this rapidly rising curve.

Though more people are vaccinated this week, vaccination is not reaching people fast enough to overcome the significant rise in cases and severe illness. And people at the highest risk (the bottom left of this graphic) are still not getting the vaccines quickly enough. We need to do better, and as experts say, we can’t vaccinate our way out of the pandemic.

Simply put, according to the Advisory Table, ‘without stronger system-level measures and immediate support for essential workers and high-risk communities, high case rates will persist through the summer.’ And more people will die.

The Ontario government announced further public health measures to help curb the spread of COVID-19. Ontario’s state of emergency and stay-at-home order will now be in effect until at least May 21, 2021. There will now be further restrictions on interprovincial travel with checkpoints at all interprovincial borders to limit border crossings.

What is the story with the Johnson and Johnson vaccine?

Many people asked me this week about the Johnson & Johnson vaccine as a U.S. health panel called for more data before deciding whether to resume the use of the one-dose shot. Canada approved the vaccine but hasn’t received any doses yet.

The CDC and FDA are investigating blood clots and low platelet levels in six women in the days after vaccination.

What we know so far:

• All six cases were women in the U.S. (the only country using the vaccine so far).

• The patients were age 18-48 years.

• Symptoms began 6-13 days after they were vaccinated.

• The clots occurred in veins that move blood from the brain.

• The women had clots AND low platelets.

• One person died, and another patient is in critical condition.

• More than 6.8 million doses of this vaccine have been given in the U.S. That represents a one in more than a million rate of occurrence (i.e., extremely rare).

It is not clear what is causing the clots. The leading hypothesis is this represents an immune response that leads to the activation of platelets leading to blood clots. This side effect has similarities with what we call ‘heparin-induced thrombocytopenia (HIT),’ where the blood thinner heparin paradoxically triggers the creation of antibodies that activate platelets. Activated platelets change from being round in shape to being spiny and stimulate the formation of blood clots.

There are too few cases to conclude, but only women have developed clots so far. There is a known interaction between estrogen and the blood clotting system, and women on oral contraceptives are at higher risk of clots, though we don’t have more data about these cases so far.

There may be a similar mechanism leading to clots from the AstraZeneca vaccine. Both the AstraZeneca and Johnson and Johnson vaccines are ‘non-replicating viral vector vaccines.’ These vaccines use a modified adenovirus to give genetic instructions to the body to build essential coronavirus proteins, stimulating antibody production.

There have been no reports of people developing clots after reviewing an mRNA vaccine (Moderna or Pfizer).

Canada is due to receive 10 million J&J vaccines this month. It is a single dose and requires only basic refrigeration. It will be devastating to lose out on this vaccine. The National Advisory Committee on Immunization should have guidance on who should or should not receive this vaccine by the time it arrives.
So far, the risk of blood clots as a complication of COVID-19 is statistically far greater than the risk from the Johnson & Johnson vaccine.

Dr. Dina, what is your silver lining this week?

I am immensely grateful to my incredible colleagues from across Ontario and Canada. Healthcare providers have demonstrated immense professionalism and are providing exceptional care in such challenging circumstances, especially in ICUs and emergency rooms across the country. I am so proud to be in such good company.

Physicians and clinicians continue to demonstrate tremendous leadership during this incredibly challenging time. In addition to regular clinical duties, many have taken on additional work such as vaccinating people against COVID-19, educating the public, and providing support for healthcare organizations.

I am humbled every day when I see the great work of my colleagues and feel proud to be a physician in Ontario. We are truly blessed to have access to such incredible healthcare providers who continue to fight for everyone’s safety and health.

I know this update is not the news any of us want to hear. We are feeling tired, frustrated, and discouraged. Everyone is under significant stress. Anxiety around the pandemic, juggling childcare and work, uncertainties for businesses, caring for older family members, and the closures of schools, gyms, and programs we rely on. We are facing many challenges. Unfortunately, things are likely to get worse before they get better. But it will get better. We just need to stay the course.

Please continue to practice public health strategies to decrease the spread of COVID-19: limit your mobility to essential trips, always wear a mask and keep 6 feet of distance when in contact with anyone outside their household. If you have an opportunity to be vaccinated, I strongly encourage you to do so as soon as possible. Any of the available vaccines are good choices. Talk to your healthcare provider if you have any questions.

We will get through this together.

Stay healthy and safe,

#YOUGOTTHIS