Resources

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 |  October 3, 2022

Brief on Primary Care Part 3: Lessons Learned for Strengthened Primary Care in the Next Phase of the COVID-19 Pandemic

It is anticipated that future waves of COVID-19 infections and sequelae of prior infections will continue to strain primary care resources in Ontario. This Brief, the final part of a 3-part series, consolidates five lessons learned to date based on the evidence presented in parts 1 and 2 of this Science Brief: Lesson 1: Care provided in formal attachment relationships and through team-based models provides superior support for COVID-19- and non-COVID-19-health issues in the community. Lesson 2: In the absence of additional resources, COVID-19 response results in trade-offs and unmet needs in other areas. Lesson 3: Innovative models and new partnerships supported patients, particularly those from equity-deserving groups, to get needed care, but infrastructure is needed for sustainability, spread, and scale. Lesson 4: The absence of an integrated and inclusive data system compromised the pandemic response in primary care. Lesson 5: Primary care can leverage its longitudinal relationships to improve population health and health system sustainability. Heeding these five lessons would strengthen and support the primary care sector in Ontario to meet expected challenges in pandemic response and recovery.
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 |  October 3, 2022

Brief on Primary Care Part 2: Factors Affecting Primary Care Capacity in Ontario for Pandemic Response and Recovery

Primary care is a crucial component of pandemic and health emergency preparedness, response, and recovery. It is also essential to continued health system improvement, person-centred care in communities, and optimal population health for Ontarians. A capacity crisis in primary care has deepened during the COVID-19 pandemic. Urgent efforts are needed to address the factors that limit primary care provision. This will include ensuring an infrastructure that supports coordinated and integrated primary care. It will also include ensuring the training, support, and retention of interdisciplinary health human resources (HHR) that comprise teams providing care associated with patient enrolment models (PEMs), so they are equitable and accessible for all Ontarians before, during, and after public health emergencies.
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 |  October 3, 2022

Brief on Primary Care Part 1: The Roles of Primary Care Clinicians and Practices in the First Two Years of the COVID-19 Pandemic in Ontario

Primary care is a critical entry point into both COVID-19- and non-COVID-19-related care in Ontario. Primary care clinicians (PCCs) played an integral and multi-faceted role in Ontario’s pandemic response. This included a rapid transition to virtual care; participating in testing, treatment, and wraparound services for COVID-19; providing education and support to local communities to increase vaccine uptake; and more recently, catching up with non-COVID care despite fixed resources. COVID-19 care is increasingly being integrated into primary care practices but without added resources or supports. At the same time, PCCs are supporting patients who experienced missed or delayed care through the pandemic. Practices funded to include interprofessional teams have inherently had more flexibility to support both the pandemic response and catch-up of non-COVID-19 care.
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 |  September 19, 2022

Effective Modalities of Virtual Care to Deliver Mental Health and Addictions Services in Canada

The delivery of virtual mental health care by regulated healthcare professionals has grown substantially since the onset of the COVID-19 pandemic. In the limited research conducted on this modality, virtual mental health care has been found to be efficacious for supporting patients with depression, anxiety, and post-traumatic stress disorder. However, there is limited comparative evidence between in-person and virtual modalities, or for severe mental illnesses such as schizophrenia or bipolar disorder. Thus, despite the surge in the use of virtual care during the pandemic, it is important to recognize that virtual care may not be an adequate substitute for in-person treatment for all populations or conditions. Further, while virtual mental health care has the potential to address barriers to access to care for rural and underserved communities, it may also propagate existing inequities in mental health care for under-resourced populations. Many challenges to the delivery of equitable care through virtual mental health remain. Enhancing technological literacy and access for clinicians and clients, and delivering culturally competent care that aligns with the needs of the local population and community is a largely unaddressed priority for advancing transparency, trust and equity. Deliberate consideration of the specific needs and issues, preferences, culture and values of individual patients and communities is important to deliver culturally-competent virtual mental health models of care for equitable, accessible recovery. This should be done through close engagement and collaborative co-creation with patients, mental health researchers, practitioners and communities.
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 |  September 7, 2022

Understanding the Post COVID-19 Condition (Long COVID) in Adults and the Expected Burden for Ontario

The post COVID-19 condition is a complex and heterogeneous syndrome that develops in people with prior SARS-CoV-2 infection. More than 100 symptoms have been reported in people with the post COVID-19 condition, and these appear to be associated with reduced quality of life, reduced function, and impairments in people’s ability to work and care for themselves. There remains significant uncertainty in the definition, magnitude of prevalence, causes, risk factors, prevention, and prognosis of the post COVID-19 condition, as well as its impact on people’s quality of life, function, and ability to work. Nonetheless, the reported range of these effects in the published literature suggest that the post COVID-19 condition poses substantial health risks to adults across a diverse range of outcomes that have the potential to impart a considerable burden on individuals and healthcare systems. More contemporary evidence in the era of widespread vaccination and emerging variants resulting in less severe illness than earlier variants suggests that the post COVID-19 condition may now be less frequent following SARS-CoV-2 infection. Still, a proactive and comprehensive strategy to manage the post COVID-19 condition needs to be developed by health systems and policy makers. This strategy should include substantial investments in research and health system resources to mitigate the long-term health, social, and economic impacts of the post COVID-19 condition in Ontario.
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 |  August 25, 2022

Infection Prevention and Control Considerations for Schools during the 2022-2023 Academic Year

In-person schooling is essential for children and youth for both academic educational attainment and for the development of social, emotional growth and life skills. Schools are a place where children gain essential academic skills, form friendships, learn social and life skills, and are key settings for physical activity. Schools provide critical services that help to mitigate health disparities, including school nutrition programs, public health services (immunizations, dental screening), health care services (speech and language therapy, occupational therapy), social services and mental health supports. Schools should therefore remain open for in-person learning. Optimizing the health and safety of children and staff in schools requires that certain health and safety measures be in place, irrespective of the COVID-19 pandemic. These “permanent” measures include achieving and maintaining adequate indoor air quality, environmental cleaning and disinfection, hand hygiene, students and staff staying home when sick and up-to-date routine and recommended immunizations for students and staff. Temporary infection-related health and safety measures (e.g., masking, physical distancing, cohorting, active screening, testing) can help reduce the transmission of communicable illnesses in schools. However, some can pose additional challenges to school operations, student learning and student wellness. Furthermore, some of these measures may adversely impact social connectedness, which is of vital importance for children of all ages and of heightened significance in the adolescent years. Therefore, a thoughtful approach based on real-time local level analysis is recommended before reintroducing these temporary measures after careful consideration of the potential benefits and negative consequences. Given that schools are not isolated from communities, implementation of these temporary measures should not be done in isolation of community measures for indoor spaces. These temporary measures are not expected to be required at the start of the 2022 school year.
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 |  June 28, 2022

Severe Acute Hepatitis in Children of Unknown Etiology

Public health agencies have raised concern over cases of acute severe hepatitis of unknown etiology in children that have been reported worldwide. Surveillance has been implemented in several jurisdictions to identify cases, investigate etiologies and monitor trends to determine if there is a signal of concern. The relationship between the COVID-19 pandemic and the genesis of these reports is yet to be fully determined. Potential etiological hypotheses have included adenovirus and SARS-CoV-2 infection. However, to date, cases reported in the published literature have had inconsistent and incomplete testing sent, limiting the epidemiological investigation. Clinicians need to be aware of how to recognize severity of acute hepatitis in children, what investigations to perform, and threshold to refer to a pediatric gastroenterologist or a liver transplant center. This document summarizes a pathway for the evaluation of children with severe acute hepatitis of unknown etiology and highlights the importance of immediately consulting with a pediatric gastroenterologist if the INR is elevated (greater or equal to than 1.5) and/or serum direct bilirubin is elevated to prioritize investigations and guide management.
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 |  June 21, 2022

The Impact of Physical Activity on Mental Health Outcomes during the COVID-19 Pandemic

Increasing physical activity and decreasing sedentary behaviour have positive effects on mental well-being and are associated with reduced symptoms of depression and anxiety. These effects were well-established prior to the COVID-19 pandemic. Overall, movement behaviours and mental health status worsened among Canadians during the COVID-19 pandemic. Physical activity in some groups, including children, has been disproportionately affected during the pandemic by measures such as school and recreation closures. Further, a lack of safe, accessible physical activity opportunities for some populations will persist past the pandemic due to structural inequities such as inequities in access to indoor or outdoor recreation spaces, as well as built environment features, which may ultimately negatively impact mental health. Promoting physical activity can help optimize both physical and mental health among Ontarians during and beyond the COVID-19 pandemic. Maintaining and improving emotional well-being through engagement in physical activity may be facilitated by providing publicly accessible and proportionally distributed indoor and outdoor recreation spaces, as well as supporting policies which address the relationship between the built environment and physical activity.
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 |  April 28, 2022

The COVID-19 Pandemic's Impact on Long-Term Care Homes: Five Lessons Learned

Older adults living in Ontario’s long-term care (LTC) homes have experienced some of the most devastating impacts of the COVID-19 pandemic, including disproportionate deaths, prolonged isolation from family and essential caregivers and reduced quality of life. In response, national and provincial associations and organizations have launched inquiries, issued expert reports, and offered recommendations. This brief summarizes and consolidates key recommendations from five reports and identifies opportunities to strengthen and integrate these recommendations into the Ontario policy environment. We identified five critical lessons learned: 1) Enhance the entry and retention of LTC home staff through the creation of more full-time positions, adequate staffing levels, and improvement of working conditions, 2) Reduce crowding through the elimination of three and four bed ward rooms and creation of more private rooms with dedicated bathrooms, 3) Maintain the ability for essential caregivers to have in-person access to the resident, 4) Ensure residents have access to timely and high-quality palliative care that promotes both quality and length of life, and 5) Build and maintain infection prevention and control (IPAC) expertise within LTC homes. These five lessons learned offer opportunities for significant improvement for Ontario’s LTC homes and can optimize safety, quality of life and outcomes for residents and improve the LTC home environment for staff and essential caregivers.
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 |  April 12, 2022

Increased Screen Time for Children and Youth During the COVID-19 Pandemic

Screen time has substantially increased for children and youth in Ontario and globally during the COVID-19 pandemic. Emergency measures introduced during the pandemic such as closures of schools and recreation contributed to increased screen time. There is a growing body of evidence associating increased screen time with harms to physical (e.g., decreased physical activity, eye strain and headaches), cognitive (e.g., attentiveness) and mental (e.g., reported symptoms of depression and anxiety) health in children and youth. There are evidence-based strategies to promote healthy screen habits for children and their families which offer an approach to encourage healthier screen use in the home setting and mitigate potential harms. However, the burden to reduce screen time cannot fall to parents and families alone. Policies are needed to avoid closures of school and recreation, and ensure alternatives to screen time for children and youth of all ages that promote socialization and physical activity. In addition, there are key equity considerations when it comes to accessibility of alternatives to screen time such as child care and community recreation.
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 |  February 23, 2022

Evidence-Based Recommendations on the Use of Nirmatrelvir/Ritonavir (Paxlovid) for Adults in Ontario

Nirmatrelvir and ritonavir are two co-administered antiviral medications, marketed under the name Paxlovid in Canada, for the treatment of SARS-CoV-2 infection. Nirmatrelvir is an inhibitor of SARS-CoV-2 3CL-like protease that prevents polyprotein cleavage of proteins necessary for SARS-CoV-2 genome replication. Nirmatrelvir has been studied in combination with ritonavir, a medication that has no known activity against SARS-CoV-2 but slows the metabolism of nirmatrelvir by inhibiting hepatic enzymes, thus “boosting” concentrations of nirmatrelvir. Nirmatrelvir/ritonavir is currently approved in Canada for the treatment of mild COVID-19 (termed “mild to moderate” with Health Canada’s terminology) in those who are at high risk for progression to severe or critical COVID-19 illness. It is not approved for the treatment of patients requiring hospitalization due to COVID-19, nor for pre- or post-exposure prophylaxis for the prevention of SARS-CoV-2 infection. As of the date of publication of this Science Brief, there is one peer-reviewed publication comparing nirmatrelvir/ritonavir against placebo. Nirmatrelvir/ritonavir reduces the incidence of hospitalization and/or death in patients with mild COVID-19 with risk factors for progression to moderate or critical illness, with fewer treatment-emergent serious adverse events relative to placebo. The panel noted a marginal benefit in individuals at low risk of hospitalization, and the high certainty of harm with nirmatrelvir/ritonavir if known drug-drug interactions are not mitigated. Critically Ill Patients (On High-Flow Oxygen, Mechanical Ventilation, or Extracorporeal Membrane Oxygenation (ECMO)) Nirmatrelvir/ritonavir is not recommended for critically ill patients with COVID-19. Moderately Ill Patients (On Low-Flow Oxygen) Nirmatrelvir/ritonavir is not recommended for moderately ill patients with COVID-19. Mildly Ill Patients (Not Requiring Supplemental Oxygen) Nirmatrelvir/ritonavir is recommended at a dose of 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet), with all three tablets taken together orally twice daily for five days. Patients must be at higher risk of severe disease from COVID-19 and present within five days of symptom onset. Risk factors for progression to moderate or critical COVID-19 are outlined in “Methods used for this Science Brief” below, and include immunocompromised individuals, and individuals whose combination of age, vaccination history, and risk factors put them at increased risk of progression to severe disease. Other treatment options that may be available to these higher risk patients include sotrovimab, remdesivir, fluvoxamine, and budesonide. Clinicians should consider patient-specific factors including (but not limited to) drug-drug interactions, renal function, duration of COVID-19 symptoms, ability to administer intravenous versus oral drugs, strength of evidence, situational context, and drug supply in decision-making regarding choice of therapy (see Therapeutic Management of Adult Patients with COVID-19 summary for additional details). If eligible patients with mild COVID-19 who began treatment with nirmatrelvir/ritonavir progress to moderate COVID-19 during their treatment course, they may complete their treatment course at the discretion of the treating physician. Implementation Considerations It is recommended that oral antiviral therapy be administered to non-hospitalized individuals across Ontario using a hybrid network that includes, but is not limited to, mobile integrated healthcare services, community paramedicine, virtual/remote assessment, and outpatient clinics. Special Populations Pharmacist consultation is important to mitigate any significant drug-drug interactions (including natural products). Nirmatrelvir/ritonavir is contraindicated in patients taking certain medications that have the potential for serious or life-threatening reactions at high concentrations and are highly dependent on CYP3A4-mediated metabolism; and in patients taking certain medications that are CYP3A-inducing, as these may significantly decrease concentrations of nirmatrelvir/ritonavir, decreasing its efficacy as a COVID-19 treatment (see Tables 1-4 in the “Considerations” section below, and the guidance document “Nirmatrelvir/ritonavir (Paxlovid): What prescribers and pharmacists need to know”). For complex interactions, consultation with a pharmacist experienced in managing ritonavir-related interactions may be helpful. In patients with moderate renal impairment (eGFR ≥30 to <60 mL/min), the dose should be reduced to 150 mg nirmatrelvir (one 150 mg tablet) and 100 mg ritonavir (one 100 mg tablet) taken together twice daily for 5 days. Nirmatrelvir/ritonavir is not recommended in patients with severe renal impairment (eGFR <30 mL/min) or who require dialysis. Nirmatrelvir/ritonavir may be considered for the treatment of pregnant patients with mild COVID-19 who otherwise meet the criteria outlined for mildly ill patients. There is a lack of data on nirmatrelvir/ritonavir use in pregnant patients; however, there is extensive experience with ritonavir use in pregnant patients living with HIV. If a pregnant patient fits the risk profile to potentially derive benefit from nirmatrelvir/ritonavir, the risks and benefits of initiating treatment should be discussed with the patient. Care of pregnant patients with COVID-19 should be managed by a multidisciplinary team with suitable expertise in the management of pregnancy. Nirmatrelvir/ritonavir may be considered for lactating patients with mild COVID-19 who otherwise meet the criteria outlined for mildly ill patients. There is a lack of data on nirmatrelvir/ritonavir use in lactating patients; however, based on studies in HIV, for which ritonavir is also used, it is known that ritonavir may be present in breast milk. If a lactating patient fits the risk profile to potentially derive benefit from nirmatrelvir/ritonavir, the risks and benefits of initiating treatment should be discussed with the patient. We recommend advising the patient not to breastfeed for the duration of treatment and four days afterwards, during which time breast milk should be pumped and discarded.
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 |  February 10, 2022

Use of Rapid Antigen Tests during the Omicron Wave

The emergence of the now provincially and globally dominant SARS-CoV-2 Omicron variant demands a reassessment of the diagnostic performance of rapid antigen tests. Rapid antigen tests are less sensitive for the Omicron variant compared to the Delta variant in nasal samples, especially in the first 1-2 days after infection. However, rapid antigen tests can more reliably detect infectious cases of the Omicron variant in combined oral-nasal samples. Individuals can collect these samples by initially swabbing both cheeks, followed by the back of the tongue or throat, and then both nostrils. In light of currently very high SARS-CoV-2 transmission rates in Ontario and the limited sensitivity of rapid antigen tests for the Omicron variant, a single negative rapid antigen test result cannot reliably rule out infection; a single negative test result is not conclusive and should not be used as a green light for abandoning or reducing precautions. Conversely, in this context, an individual with a positive rapid test result should be considered and managed as a case of COVID-19 and should immediately isolate; additional confirmation by polymerase chain reaction (PCR) is not necessary in most settings. If asymptomatic testing strategies are considered, rapid antigen tests need to be performed frequently to be effective. When using ‘Test-to-Stay’ strategies as an alternative to large-scale isolation, asymptomatic close contacts of a positive case need to do rapid antigen testing daily. When using ‘Voluntary Asymptomatic Screen Testing’ strategies, asymptomatic individuals should do rapid antigen testing 3-5 times per week.
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