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Based on Ontario cremation data, there has been a 12.8% increase in the number of deaths during the COVID-19 pandemic, compared to the expected numbers of deaths informed by previous years’ cremation data. The causes of these excess deaths include infection with SARS-CoV-2, as well as causes likely related to the pandemic but not due to COVID-19 itself.

Published estimates of the risk of vaccine-induced thrombotic thrombocytopenia (VITT) from countries with moderate to high data quality range from 1 case per 26,500 to 1 case per 127,300 first doses of AstraZeneca/COVISHIELD administered (Table 1). The risk of VITT in Canada as of May 8, 2021 has been estimated to be approximately 1 per 55,000 doses, but several presumptive cases are still under investigation.

https://covid19-sciencetable.ca/sciencebrief/vaccine-induced-immune-thrombotic-thrombocytopenia-vitt-following-adenovirus-vector-covid-19-vaccination-lay-summary

Remdesivir, a direct-acting antiviral agent, may reduce mortality and progression to mechanical ventilation in moderately ill patients hospitalized with COVID-19 on supplemental low-flow oxygen. The benefits of remdesivir for critically ill patients requiring supplemental oxygen via high-flow nasal cannula or mask, or non-invasive mechanical ventilation, is uncertain. Remdesivir does not benefit and may harm critically ill patients already receiving mechanical ventilation or requiring extra-corporeal membrane oxygenation (ECMO), and it does not provide substantial benefit for hospitalized patients who do not require supplemental oxygen. Remdesivir appears to have comparable effects when used for 5 days or 10 days, and does not appear to be associated with significant adverse effects. Remdesivir is recommended in moderately ill hospitalized patients with COVID-19 requiring supplemental oxygen (Figure 1). Remdesivir may be considered for patients requiring oxygen supplementation via high-flow nasal cannula or mask, or non-invasive mechanical ventilation. It should not be used in critically ill patients on mechanical ventilation or those receiving ECMO. Remdesivir should not be used in patients who do not require supplemental oxygen.

Multiple jurisdictions have adopted or adapted paid sick leave policies to reduce the likelihood of employees infected with SARS-CoV-2 presenting to work, which can lead to the spread of infection in workplaces. During the COVID-19 pandemic, paid sick leave has been associated with an increased likelihood of workers staying at home when symptomatic. Paid sick leave can support essential workers in following public health measures. This includes paid time off for essential workers when they are sick, have been exposed, need to self-isolate, need time off to get tested, when it is their turn to get vaccinated, and when their workplace closes due to an outbreak. In the United States, the introduction of a temporary paid sick leave, resulted in an estimated 50% reduction in the number of COVID-19 cases per state per day. The existing Canada Recovery Sickness Benefit (CRSB) cannot financially protect essential workers in following all public health measures, places the administrative burden of applying for the benefit on essential workers, and neither provides sufficient, nor timely payments. Table 1 lists the characteristics of a model paid sick leave program as compared with the CRSB. Implementation of the model program should be done in a way that is easy to navigate and quick for employers.

Ontario’s initial mass COVID-19 vaccination strategy in place until April 8, 2021 was based on per-capita regional allocation of vaccines with subsequent distribution – in order of relative priority – by age, chronic health conditions and high-risk congregate care settings, COVID-19 hotspots, and essential worker status. Early analysis of Ontario’s COVID-19 vaccine rollout reveals inequities in vaccine coverage across the province, with residents of higher risk neighbourhoods being least likely get vaccinated. Accelerating the vaccination of COVID-19 hotspots and essential workers will prevent considerably more SARS-CoV-2 infections and COVID-19 hospitalizations, ICU admissions and deaths as compared with Ontario’s initial mass vaccination strategy (Figure 1).

Homebound individuals face substantial barriers to receiving COVID-19 vaccines as they cannot or rarely leave their homes because of medical, psychiatric, cognitive, functional, transportation-related and social reasons. There are at least 75,000 Ontarians aged 65 years and above who are homebound, with the majority being women and people aged 85 years and above. Much of this older homebound population requires mobile in-home COVID-19 vaccination, which could be prioritized by residence in high SARS-CoV-2 risk neighbourhoods.

New variants of concern (VOCs) now account for 67% of all Ontario SARS-CoV-2 infections. Compared with early variants of SARS-CoV-2, VOCs are associated with a 63% increased risk of hospitalization, a 103% increased risk of intensive care unit (ICU) admission and a 56% increased risk of death due to COVID-19. VOCs are having a substantial impact on Ontario’s healthcare system. On March 28, 2021, the daily number of new SARS-CoV-2 infections in Ontario reached the daily number of cases observed near the height of the second wave, at the start of the province-wide lockdown, on December 26, 2020. The number of people hospitalized with COVID-19 is now 21% higher than at the start of the province-wide lockdown, while ICU occupancy is 28% higher (Figure 1). The percentage of COVID-19 patients in ICUs who are younger than 60 years is about 50% higher now than it was prior to the start of the province-wide lockdown. Because the increased risk of COVID-19 hospitalization, ICU admission and death with VOCs is most pronounced 14 to 28 days after diagnosis, there will be significant delays until the full burden to the health care system becomes apparent.

This Science Brief provides information for health care professionals about Vaccine Induced Prothrombotic Immune Thrombocytopenia (VIPIT), a rare adverse event following the AstraZeneca vaccine. This brief describes the pathophysiology, presentation, diagnostic work-up and treatment of VIPIT. Figure 1 presents a decision tree for diagnosis and rule out of VIPIT.

Naturally occurring retirement communities (NORCs) are apartment, condo, co-op and social housing buildings that while not purpose-built for older adults, have become home to a high number of them. In Toronto, there are 489 residential buildings that are NORCs. Of these, 256 are located in neighbourhoods with the highest cumulative incidence of SARS-CoV-2, and are home to 40,955 older adults 65 years of age and above, including 18,144 older adults 80 years of age and above. Prioritizing COVID-19 vaccination by both age and neighbourhood of residence is an effective strategy to minimize deaths, morbidity, and hospitalization. Targeting people living in NORCs in high-risk neighbourhoods for early vaccination is a practical application of that strategy, which will also address barriers to vaccination in this population.

As Ontario expands access to the COVID-19 vaccine beyond the Phase 1 priority populations, strategic planning and execution of mass vaccine rollout will have a significant impact on the health and safety of Ontario’s 14.5 million residents. There are six key elements of Israel’s successful COVID-19 vaccine campaign that can be readily applied to Ontario to expedite and expand the province’s vaccine rollout strategy: a simple vaccine prioritization process; modification to the transport, storage, and distribution of the vaccines; effective communication to promote vaccine confidence; decentralization of vaccination sites; centralized organization through Health Maintenance Organizations (HMOs) using a fully integrated information technology (IT) system in a universal health care system; and the engagement of community-based personnel, infrastructure, and resources.

Key Message Accelerating the rollout of Ontario’s COVID-19 vaccine such that all LTC residents receive the first dose of a COVID-19 vaccine by January 31, 2021, would prevent a projected 600 COVID-19 cases and 115 deaths by March 31, 2021 when compared with the province’s current plan to vaccinate all LTC residents by February 15, 2021. Projections indicate that further acceleration of the rollout would prevent even more COVID-19 cases and deaths. If vaccine supply is limited, the early provision of first doses of a COVID-19 vaccine to LTC home residents is likely to be more beneficial than the on-schedule provision of second doses to health care workers outside of LTC homes. All LTC residents should receive the second dose according to approved vaccination schedules.

Key Message Ontario long-term care (LTC) home residents have experienced disproportionately high morbidity and mortality, both from COVID-19 and from the conditions associated with the COVID-19 pandemic. There are several measures that could be effective in preventing COVID-19 outbreaks, hospitalizations, and deaths in Ontario’s LTC homes, if implemented. First, temporary staffing could be minimized by improving staff working conditions. Second, homes could be further decrowded by a continued disallowance of three- and four-resident rooms and additional temporary housing for the most crowded homes. Third, the risk of SARS-CoV-2 infection in staff could be minimized by approaches that reduce the risk of transmission in communities with a high burden of COVID-19. Summary Background The Province of Ontario has 626 licensed LTC homes and 77,257 long-stay beds; 58% of homes are privately owned, 24% are non-profit/charitable, 16% are municipal. LTC homes were strongly affected during Ontario’s first and second waves of the COVID-19 pandemic. Questions What do we know about the first and second waves of COVID-19 in Ontario LTC homes? Which risk factors are associated with COVID-19 outbreaks in Ontario LTC homes and the extent and death rates associated with outbreaks? What has been the impact of the COVID-19 pandemic on the general health and wellbeing of LTC residents? How has the existing Ontario evidence on COVID-19 in LTC settings been used to support public health interventions and policy changes in these settings? What are the further measures that could be effective in preventing COVID-19 outbreaks, hospitalizations, and deaths in Ontario’s LTC homes? Findings As of January 14, 2021, a total of 3,211 Ontario LTC home residents have died of COVID-19, totaling 60.7% of all 5,289 COVID-19 deaths in Ontario to date. There have now been more cumulative LTC home outbreaks during the second wave as compared with the first wave. The infection and death rates among LTC residents have been lower during the second wave, as compared with the first wave, and a greater number of LTC outbreaks have involved only staff infections. The growth rate of SARS-CoV-2 infections among LTC residents was slower during the first two months of the second wave in September and October 2020, as compared with the first wave. However, the growth rate after the two-month mark is comparatively faster during the second wave. The majority of second wave infections and deaths in LTC homes have occurred between December 1, 2020, and January 14, 2021 (most recent date of data extraction prior to publication). This highlights the recent intensification of the COVID-19 pandemic in LTC homes that has mirrored the recent increase in community transmission of SARS-CoV-2 across Ontario. Evidence from Ontario demonstrates that the risk factors for SARS-CoV-2 outbreaks and subsequent deaths in LTC are distinct from the risk factors for outbreaks and deaths in the community (Figure 1). The most important risk factors for whether a LTC home will experience an outbreak is the daily incidence of SARS-CoV-2 infections in the communities surrounding the home and the occurrence of staff infections. The most important risk factors for the magnitude of an outbreak and the number of resulting resident deaths are older design, chain ownership, and crowding. Figure 1. Anatomy of Outbreaks and Spread of COVID-19 in LTC Homes and Among Residents Figure from Peter Hamilton, personal communication. Many Ontario LTC home residents have experienced severe and potentially irreversible physical, cognitive, psychological, and functional declines as a result of precautionary public health interventions imposed on homes, such as limiting access to general visitors and essential caregivers, resident absences, and group activities. There has also been an increase in the prescribing of psychoactive drugs to Ontario LTC residents. The accumulating evidence on COVID-19 in Ontario’s LTC homes has been leveraged in several ways to support public health interventions and policy during the pandemic. Ontario evidence showed that SARS-CoV-2 infections among LTC staff was associated with subsequent COVID-19 deaths among LTC residents, which motivated a public order to restrict LTC staff from working in more than one LTC home in the first wave. Emerging Ontario evidence on risk factors for LTC home outbreaks and deaths has been incorporated into provincial pandemic surveillance tools. Public health directives now attempt to limit crowding in LTC homes by restricting occupancy to two residents per room. The LTC visitor policy was also revised to designate a maximum of two essential caregivers who can visit residents without time limits, including when a home is experiencing an outbreak. Several further measures could be effective in preventing COVID-19 outbreaks, hospitalizations, and deaths in Ontario’s LTC homes. First, temporary staffing could be minimized by improving staff working conditions. Second, the risk of SARS-CoV-2 infection in staff could be minimized by measures that reduce the risk of transmission in communities with a high burden of COVID-19. Third, LTC homes could be further decrowded by a continued disallowance of three- and four-resident rooms and additional temporary housing for the most crowded homes. Other important issues include improved prevention and detection of SARS-CoV-2 infection in LTC staff, enhanced infection prevention and control (IPAC) capacity within the LTC homes, a more balanced and nuanced approach to public health measures and IPAC strategies in LTC homes, strategies to promote vaccine acceptance amongst residents and staff, and further improving data collection on LTC homes, residents, staff, visitors and essential caregivers for the duration of the COVID-19 pandemic. Interpretation Comparisons of the first and second waves of the COVID-19 pandemic in the LTC setting reveal improvement in some but not all epidemiological indicators. Despite this, the second wave is now intensifying within LTC homes and without action we will likely experience a substantial additional loss of life before the widespread administration and time-dependent maximal effectiveness of COVID-19 vaccines. The predictors of outbreaks, the spread of infection, and deaths in Ontario’s LTC homes are well documented and have remained unchanged between the first and the second wave. Some of the evidence on COVID-19 in Ontario’s LTC homes has been effectively leveraged to support public health interventions and policies. Several further measures, if implemented, have the potential to prevent additional LTC home COVID-19 outbreaks and deaths.

Administering Pfizer-BioNTech’s COVID-19 vaccine during the early stage of the vaccine rollout (January/February 2021) to as many individuals as possible would prevent more COVID-19 cases in Ontario as compared to reserving half of the initial allotments as second booster doses (Figure 1). On-label use of the vaccine with the administration of two doses is important, as the second dose significantly boosts the immune response and results in a substantial increase in neutralizing antibodies. However, using 100% of the initial allotments immediately to vaccinate as many individuals as possible does not preclude on-label use with two doses, even though the interval between first and second booster dose may become longer than 21 days.