Primary Care Open Forum Summary Document (Apr21)
COVID-19 Support for Primary Care
Discussion Forum – April 21, 2021
To support primary care during the COVID-19 pandemic, East Toronto Family Practice Network (EasT-FPN), in collaboration with Michael Garron Hospital’s Dr. Jeff Powis - Medical Director, IPAC, hosts a virtual Primary Care Q+A Open Forum to provide clinical & practice recommendations. Join us bi-weekly. Get additional practice support and strengthen East Toronto, by becoming a member of the EasT-FPN.
Key Updates & Summary of Apr 21/2021 Discussion
There continues to be decreasing ICU capacities across the province, driven primarily by Toronto. We are no longer able to transfer patients to the East End of the region because they now have their capacities increasing by their own patients.
We are continuing to focus on FSA neighbourhoods, mainly M1H, M4H, M3C, and M4A and are administering vaccinations through mobile work and informal community hubs. We are limited by vaccine supply, but will continue with our mobile based strategy.
Thank you for your continued support in signing up for shifts at the pop-up clinics and vaccination clinics. We have had to cancel and rebook shifts due to the changes in vaccine supply, but shifts are posted last minute so please keep an eye on the scheduler.
There are opportunities for primary care clinics in East Toronto to take part in the AstraZeneca vaccine distribution. Please submit your numbers to East-FPN.
Question and Answer:
Q: Given the recent Lancet article suggesting a strong correlation between early budesonide use and decreased morbidity in COVID-19 patients, would you suggest that we prescribe this to our patients who test positive for COVID-19 within the first seven days and are symptomatic?
A: There are a small number of individuals in the trial. The demographic data shows that people with asthma get less sick with COVID-19. We have not yet given the prescription out to everyone, but a larger trial will be conducted soon. The challenge will be educating patients on how to medicate appropriately.
Q: How can we work with MGH to take more vaccines into workplaces? Would it be possible to take in the AstraZeneca vaccine to administer in these workplaces?
A: We have reached out to many workplaces to arrange to administer vaccines once we get supply. We should advocate for more Pfizer and Moderna to take into workplaces because it will make it easier to deliver. It might be a challenge to operationalize a mass clinic with AstraZeneca because of the lack of time to educate the patients.
Q: How much leeway is there at a vaccination clinic for target populations? Childcare workers and early childhood educators who are all still working at daycares are not in the prioritized population, while teachers that are no longer working in schools are prioritized. Can the early childhood educators sign up and get vaccinated anyway?
A: We try to follow the Ministry’s guidance as closely as we can, so vaccinations are provided in a similar way for equitable access across the province. There is some leeway, but we stay as close as possible to provincial guidelines on who can be vaccinated.
Q: Can you comment on that whole discussion around airborne transmission by the B117 variant? We worry about running our vaccination clinics parallel to seeing regular clinics and sick-clinic traffic. We have hepa filters running at high capacity, is that enough?
A: It is predominantly transmitted through respiratory droplets and contact. There are certain circumstances where airborne transmission can occur. We should focus on those occasions to minimize risks by avoiding closed spaces with little circulation. We should focus on the number of individuals in the clinics and organize there to be fewer individuals in the space, while thinking about opening windows for ventilation.
Q: Are all positive COVID-19 tests tested for the variants of concern?
A: Yes they are all tested for variants, but the test results are not available at MGH EMR. They are available on Connecting Ontario to see if they are tested positive for a variant of concern. Almost all current variants are the B117 variant. There are very few variants from India arising, but we are continuing our screening process and travel history is very important.
Q: There is a Provincial antigen screening program that will provide a rapid testing device and supplies to organizations to do proactive rapid point of care antigen testing for asymptomatic staff as an additional safety measure and to reduce the spread of COVID-19. Can you comment on this for use in a primary healthcare setting, such as Thorncliffe, where the incidence of COVID-19 is high and many doctors’ offices are open?
A: The viral load for the variants of concern are higher, which makes antigen testing more valuable. A daily Panbio test works best for the presymptomatic phase. The testing should be conducted before the person enters the clinic. We do not know how to operationalize without slowing down the clinic. The Panbio should be a part of the workplace as a screening for sites with more than ten employees, but there are challenges that come with the testing.
Q: You mentioned construction workers driving testing at MGH. If we are experiencing positive tests with some facility/cleaning staff would you recommend all third party facility workers get tested prior to coming onsite? How often? We know that many of these contract workers are not vaccinated and have declined vaccines.
A: We are hoping for the workers to do Panbio testing before entry, then conducting a PCR if they have positive results.
Q: Is the Point-of-care testing available the same as what was used last summer with a 60% sensitivity or is there a better test available now?
A: The B117 viral load is higher, so the tests have a better sensitivity.
Q: Can you comment on the appropriate wait time for vaccination after a patient has had COVID-19? This has come up a few times for doctors working at the vaccination clinics and we want to ensure we have a consistent message.
A: The immune response maximizes if you wait 28 days. If they are never going to come back then it is better to vaccinate them. If they are willing to come back in two weeks, they will get the most out of the vaccine on day 28.
Q: We have been doing education sessions with seniors, and shelters over Zoom. Can we have these sessions for workplaces?
A: If we are given the mandate to immunize more central workers, we will be able to start doing these sessions for them.
Q: I realize the risk of transmission from fomite contact and surfaces is low. We have still been cleaning rooms in between patients. With decreased resources, do you think it is reasonable to stop or just continue?
A: It is wise to continue to clean surfaces in between patients with hydrogen peroxide wipes.
Q: Do you think the P1 variant will be coming from the West coast? How are the vaccines faring against this variant?
A: Toronto now has more of the P1 variant than the West coast, but it originally came from the West. We are still optimistic because there have been two Long-term Care workers that had tested positive for the P1 variant, with CT values under 10. There was no transmission to the Long-term Care residents that were immunized, which shows the vaccine will be efficient in preventing hospitalization and severe disease for the P1 variant.
Q: For the AstraZeneca vaccine, are there certain patients we should not be giving it to?
A: The mechanism of vaccine clot formation is not the same as thrombophilia. The main risk factors found were females more than males and younger aged patients more than older. The causes of blood clotting have not yet been clearly identified.
Q: There are lots of kids who have done the oral-nasal swab and have come back for retesting because they had indeterminate results. Is this an inherent problem of the oral-nasal swab or because of leaky tubes?
A: The oral-nasal does not pick up as much of the virus. They do not need to come back for testing. The indeterminate results are usually positive, but kids clear viruses quickly and are rarely symptomatic. There was a leaky batch of tubes because they had a different cap, but that has since been fixed.