COVID-19: Comparing mortality rate in long-term care homes in Ontario and British Columbia.

Season's Greetings and Happy New Year (Dr. Noorali Bharwani)
Season's Greetings and Happy New Year (Dr. Noorali Bharwani)

An article in the Canadian Medical Association Journal (CMAJ November 23, 2020 – COVID-19 in long-term care homes in Ontario and British Columbia) compares care and mortality rate in the long-term care institutions in these two provinces.

The article emphasis five important points:

  1. Many more residents living in Ontario long-term care homes have died from coronavirus disease 2019 (COVID-19) than in British Columbia.
  2. Before the pandemic, the long-term care system in British Columbia exhibited a number of potential strengths relevant to pandemic preparedness compared with Ontario. These were:
    • there was better coordination between long-term care, public health and hospitals
    • there was greater funding of long-term care;
    • there was more care hours for residents;
    • fewer shared rooms;
    • more non-profit facility ownership;
    • more comprehensive inspections.
  3. During the first wave of the pandemic, British Columbia was faster than Ontario in responding to COVID-19, with actions to address public health support, staffing, and infection prevention and control.
  4. Leaders in British Columbia were more decisive, coordinated and consistent in their overall communication and response.

People living in long-term care homes in Canada have been far more likely to die of coronavirus disease 2019 than the rest of the population. However, the effect of COVID-19 on residents in long term care has varied across provinces and territories.

The authors of the CMAJ article say, “Our analysis suggests that the difference in outcome has been primarily due to differential risk in residents in long term care acquiring SARS-CoV-2.”

There are many reasons why COVID-19 affected nursing home patients in British Columbia did better than nursing home patients in Ontario. One of the reasons was, nursing home residents in Ontario were more likely to reside in shared rooms (63 per cent of residents) than those in British Columbia (24 per cent).

Overview of Restoring Trust: COVID-19 and The Future of Long-Term Care, is a Policy Briefing Report on Long-Term Care. The report begins by reviewing the research context and policy environment in Canada’s long-term care sector before the arrival of COVID-19. The report makes several suggestions to improve care in nursing homes. I will just mention a few.

  • All long-term care homes must have comprehensive plans for preventing and managing infectious disease outbreaks.
  • Public health units must conduct regular and unannounced inspections.
  • Long term care homes should have adequate personal protective equipment (PPE).
  • Staff at long-term care homes must have the option for full-time work with equitable wages, benefits and pandemic work supports including sick leave and mental health support.

All long-term care homes must have the capacity to isolate residents in the event of an outbreak.

Residents in long-term care homes will always be vulnerable to infectious pathogens. The experience to date suggests that better preparedness and responses could save the lives of thousands of people living in long term care homes in Canada.

The year is coming to an end. Do not forget to use your PPE diligently. Follow the guidelines set by our Chief Medical Officer of Health, Dr. Deena Hinshaw.

Let me wish you all Merry Christmas, Season’s Greetings and Happy New Year. May you all be blesses with good health and happiness. As some body has said, tough times never last but tough people do. Research has shown positive thinkers do better in life. Maybe even as much as 40 per cent of our happiness is due to actions that we control.

Take care. Be safe.

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COVID Can Have Lingering Effects

Sunset in St. Martin - an island in the Caribbean Sea. (Dr. Noorali Bharwani)
Sunset in St. Martin - an island in the Caribbean Sea. (Dr. Noorali Bharwani)

About 80 per cent of the people with COVID-19 recover from the disease without needing special treatment. Majority of the children and young adults do well as well. But some people are not so lucky. They end up with serious illness.

Around 20 per cent of the people who are infected with COVID-19 develop difficulty in breathing and require hospital care. People who are aged over 60 years, and people who have underlying medical conditions such as diabetes, heart disease, respiratory disease or hypertension are among those who are at greater risk.

Current evidence suggests that the severity of COVID-19 disease is higher among smokers. Smoking impairs lung function, making it more difficult for the body to fight off respiratory disease due to the virus. Quite often these patients end up in ICU.

COVID-19 patients (smokers or non-smokers) who end up in ICU face many challenges. Studies have shown prolonged length of stay in ICUs is associated with long-term disability. About 25 – 80 per cent of patients admitted to an ICU will have new or worsened physical, and mental health impairments that persist beyond discharge from the hospital.

In those with a prolonged length of stay, defined as one week or longer of mechanical ventilation, patient age and length of stay in an ICU affect their mental and physical functions at one year after discharge from the ICU. Unfortunately, physical impairments after critical illness can last for years.

Long term exposure to sedation and immobility in the ICU leads to severe weakness. This prolongs the recovery time. This can affect up to 50 per cent of patients discharged from the ICU. The weakness may persist after hospital discharge, lasting more than 24 months in about 10 per cent of cases.

Fatigue, joint contractures and peripheral nerve injuries are frequently reported, affecting activities of daily living, including grooming, feeding, bathing and walking.

Many COVID-19 ICU patients have problems with memory, attention, problem solving and execution of complex tasks. This may persist one year after discharge form the ICU.

Up to 35 per cent of patients may end with mental health disorders. Even caregivers may be affected with mental health issues. Anxiety, depression and posttraumatic stress disorder can affect COVID-19 patients and their caregivers.

No robust intervention has been shown consistently to improve recovery after prolonged ICU stay.  A comprehensive multidisciplinary approach that includes rehabilitation specialists, psychiatrists and neurologists may be required and continue after hospital discharge.

What is the recovery time for the coronavirus disease?

The median time from onset to clinical recovery for mild cases is approximately two weeks and is three to six weeks for patients with severe or critical disease.

Mortality rate has improved over the last six months or so as scientists are learning more about the disease. The mortality is broadly consistent across the world; as the pandemic has progressed. ICU mortality rates have reduced from more than 50 per cent in March 2020 to close to 40 per cent at the end of May 2020. It may be better now.

Prevention is better than going to ICU. So, continue to follow prevention guidelines as they evolve as we learn more about the new virus. Wear a mask, maintain physical distance, wash your hands frequently and take care of your family and friends.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Understanding the Concept of ‘Herd Immunity’

Niagara Falls (Dr. Noorali Bharwani)
Niagara Falls (Dr. Noorali Bharwani)

According to WHO website, ‘herd immunity’, also known as ‘population immunity’, is a concept used for vaccination, in which a population can be protected from a certain virus if a threshold of vaccination is reached.

If 90 per cent of the population is vaccinated then the rest of the population is generally protected by the concept of herd immunity. Herd immunity is achieved by breaking the chain of transmission of the virus by immunization.

Important point is herd immunity is achieved by protecting people from a virus, not by exposing them to it.

Unfortunately, herd immunity cannot be achieved with COVID-19.

Currently, we do not have a vaccine against the virus. Vaccines train our immune systems to create proteins (antibodies) that fight disease, just as would happen when we are exposed to a disease. Vaccines work without making us sick.

The percentage of people who need to have antibodies in order to achieve herd immunity against a particular disease varies with each disease. For example, herd immunity against measles requires about 95 per cent of a population to be vaccinated. The remaining five per cent will be protected by the fact that measles will not spread among those who are vaccinated. For polio, the threshold is about 80 per cent, says WHO website.

There are two ways to herd immunity for COVID-19 – vaccines and infection.

Vaccines: Using the concept of herd immunity, vaccines have successfully controlled deadly contagious diseases such as smallpox, polio, diphtheria, rubella and many others. People who oppose vaccines do pose a real challenge to herd immunity.

Natural infection: Herd immunity can also be reached when a sufficient number of people in the population have recovered from a disease and have developed antibodies against future infection.

However, there are some major problems with relying on community infection to create herd immunity.

It isn’t yet clear if infection with the COVID-19 virus makes a person immune to future infection. Even if infection with the COVID-19 virus creates long-lasting immunity, a large number of people would have to become infected to reach the herd immunity threshold.

Experts estimate that in the U.S., 70 per cent of the population – more than 200 million people – would have to recover from COVID-19 to halt the epidemic. If many people become sick with COVID-19 at once, the health care system could quickly become overwhelmed. This amount of infection could also lead to serious complications and millions of deaths, especially among older people and those who have chronic conditions.

In most countries, less than 10 per cent of the population have been infected with COVID-19. It would be scientifically problematic and unethical to expose millions of people to the virus to achieve herd immunity. Letting COVID-19 spread through populations, of any age or health status will lead to unnecessary infections, suffering and death.

We are still learning about immunity to COVID-19. Most people who are infected with COVID-19 develop an immune response within the first few weeks, but we don’t know how strong or lasting that immune response is, or how it differs for different people. There have also been reports of people infected with COVID-19 for a second time.

Until we better understand COVID-19 immunity, it will not be possible to know how much of a population is immune and how long that immunity last for, let alone make future predictions.

It is crucial to slow the spread of COVID-19 virus and protect individuals at increased risk of severe illness. Wear a mask in public, maintain social distance, avoid big gatherings and wash your hands frequently.

Prevention is better than cure. If you have cough, fever, and difficulty breathing, seek medical care early.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

How to Lose Weight During the Pandemic

Golden Gate Bridge in San Francisco. (Dr. Noorali Bharwani)
Golden Gate Bridge in San Francisco. (Dr. Noorali Bharwani)

Are you overweight or obese? Easy way to find out is by measuring your height and girth. Your girth should be half the size of your height.

Studies have shown obesity is a significant factor for critical illness during COVID-19. Obesity was also an important factor for mortality in patients with COVID-19. This is most likely due to obese patients were known to have a defective immune system that makes them vulnerable to a type of infection that specifically require a prompt cellular immune response (Obes Res Clin Pract. 2020 July-August).

The current pandemic has changed people’s social life limiting outdoor activities. They gain weight. It is known as “Quarantine 15”. Many people have put on 15 or more pounds in weight during the last six months or so.

The weight gain is not a surprise if you have a sedentary lifestyle. With gyms closed and groceries delivered, it was easy to lounge around and eat. People working from home have additional stress of managing family and keeping up with work schedule. Binge eating, snacking and comfort eating was a psychologically verified response to stress.

Stress and depression are going to affect your weight. When you are under stress your body tries to protect you by not giving up any calories. Plus, you tend to eat more when you are depressed.

According to the Centers for Disease Control and Prevention (CDC), severe obesity increases the risk of a dangerous breathing problem called acute respiratory distress syndrome (ARDS), which is a serious complication of COVID-19.

Also, people with severe obesity are more likely to have other chronic diseases and health conditions that can increase the severity of COVID-19.

The immune response to infection is altered in overweight patients. We do not know how effective a COVID-19 vaccine will be for these individuals.

Losing five or 10 pounds during the pandemic is entirely possible. Weigh yourself at least once a week. People who weigh themselves are more likely to keep their weight down.

Dr. John Morton, MD, medical director of bariatric surgery at Yale New Haven Health System, says he has seen patients in telehealth appointments who have gained five, 10, and even 30 pounds during the pandemic (Yale Medicine, July 1, 2020). They are looking for ways to lose weight.

How to lose weight during the pandemic?

The first step is to come up with a plan, says Dr. Morton. He recommends building new routines around what he calls the four pillars for weight loss: diet, exercise, sleep, and stress management. You have to have a disciplined routine otherwise it does not work.

“That means getting up in the morning, taking a shower, getting breakfast, and having a plan for the day. Purpose gives direction, and it helps when it comes to weight,” says Dr. Martin.

One or two pounds a week is a reasonable weight loss pace, Dr. Morton says. “If you want to cut back by 500 calories a day, that might mean you are exercising the equivalent of 200 calories and cutting out 300 calories in your diet.” It can be done.

Where there is a will there is a way. Be safe and stay healthy.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!