Resources

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 |  January 8, 2022

Baricitinib for Hospitalized Patients with COVID-19

Baricitinib, a Janus-associated kinase (JAK) inhibitor, reduces mortality and may reduce progression to mechanical ventilation in COVID-19 patients, with no increase in serious adverse events. Baricitinib should be used in moderately ill patients (i.e., requiring supplemental oxygen via nasal prongs) and critically ill hospitalized patients (i.e., requiring oxygen via high-flow nasal cannula, non-invasive ventilation (NIV), invasive mechanical ventilation (IMV) or extracorporeal membrane oxygenation (ECMO)) with COVID-19 who are on recommended doses of dexamethasone (or another dose-equivalent corticosteroid) or who have a contraindication to corticosteroids. Combined use of baricitinib and interleukin-6 (IL-6) inhibitors is not recommended due to a lack of efficacy and safety data. Decisions regarding the use of baricitinib versus an IL-6 inhibitor should be made based on clinical judgement and patient preference regarding availability, side effects and contraindications. The baricitinib dose should be 4 mg PO or NG (2 x 2 mg tablets) daily for 14 days or until discharge. This should be reduced to 2 mg daily in patients with an eGFR 30-60 mL/min/1.73m2. It should not be used in patients with eGFR <30 mL/min/1.73m2.
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 |  December 23, 2021

Ask Ontario’s Science Table: Omicron Edition

This slide deck was prepared by the members of the Behavioural Science Working Group and Science Advisory Table to respond to frequently asked questions about staying safe this holiday season given the 5th wave of COVID-19 and Omicron variant.
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 |  December 9, 2021

Rapid Antigen Tests for Voluntary Screen Testing

Individuals infected with the provincially and globally dominant SARS-CoV-2 Delta variant demonstrate viral loads that peak sooner after exposure compared to those infected with previous strains of SARS-CoV-2. High SARS-CoV-2 viral loads are likely present before symptoms. These characteristics make the Delta variant challenging to control; however, they may also improve the performance and expand the practical utility of rapid antigen tests. In this Science Brief, we determined whether cases with high viral loads/low cycle thresholds are likely to be infectious, and if so, whether rapid antigen tests can reliably detect those cases. Voluntary screen testing entails regular voluntary testing of asymptomatic individuals to find cases in moderate-risk settings such as schools and workplaces. We found that rapid antigen tests can be a useful tool to reduce transmission in schools when used for voluntary screen testing to identify infectious cases in Public Health Units or neighborhoods using the following thresholds: Once a Public Health Unit or neighborhood approaches 50 new COVID-19 cases per million per day (corresponding to 35 cases per 100,000 per week) and is in sustained exponential growth, we advise weekly voluntary screen testing of unvaccinated and incompletely vaccinated individuals in elementary schools. Public health units in this situation may also decide to deploy rapid antigen testing in other settings, such as workplaces and congregate settings. If a Public Health Unit’s or neighborhood’s new daily case rate approaches 250 COVID-19 cases per million per day (corresponding to 175 cases per 100,000 per week), weekly testing is likely not frequent enough to reduce spread effectively. In that case, we advise testing unvaccinated and incompletely vaccinated individuals 2 to 3 times per week. Public health units in this situation may also consider voluntary screen testing of fully vaccinated individuals at the same frequency. Rapid antigen tests may also present a valuable alternative to individual isolation after exposure in schools. Implementing voluntary “test to stay” protocols, where exposed students remain in school as long as daily tests are negative for SARS-CoV-2, could help prevent the harms of isolation without increasing transmission. Individuals with positive rapid antigen tests should immediately isolate and undergo confirmatory Polymerase Chain Reaction (PCR) testing. Evaluation of the performance of rapid antigen tests for the diagnosis of the Omicron variant is urgently needed.
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 |  November 30, 2021

Critical Care Capacity During the COVID-19 Pandemic

From March 20, 2020 to October 31, 2021, 9,096 Ontarians have been admitted to intensive care units (ICUs) with COVID-19 related critical illness. The COVID-19 pandemic has strained Ontario’s critical care system. At the peak of wave 3, the number of patients on ventilators was over 180% of pre-pandemic historical averages. The critical care system was able to accommodate this influx of patients by deferring surgeries and procedures, funding new ICU beds, identifying temporary surge space, team-based care models utilizing redeployed staff, and transferring patients between hospitals. This required effective collaboration and coordination across critical care system. The critical care system does not currently have capacity to accommodate a surge as it did during waves 2 and 3 due to worsening staffing shortages, healthcare worker burnout, and health system recovery efforts. Public health measures to mitigate influxes of critically ill patients are needed.
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 |  November 24, 2021

Evidence-Based Recommendations on the Use of Anti-SARS-CoV-2 Monoclonal Antibodies (Casirivimab + Imdevimab, and Sotrovimab) for Adults in Ontario

Critically and Moderately Ill Patients In clinically unstable patients with no history of COVID-19 infection or having received a full recommended schedule of vaccination, casirivimab + imdevimab at a dose of 2400 mg intravenous (IV) is recommended if patients are within 9 days of onset of any COVID-19 symptom AND have demonstrated rapid clinical deterioration. Antibody testing is not required in this case. In clinically stable patients with or without a history of COVID-19 infection or having received a full recommended schedule of vaccination, casirivimab + imdevimab at a dose of 2400 mg IV may be considered if patients are within 9 days of onset of any COVID-19 symptom AND are not at risk of acute decompensation AND if COVID-19 anti-spike antibody testing demonstrates that they are seronegative. Casirivimab + imdevimab is not recommended for moderately/critically ill patients who are beyond 9 days of onset of any COVID-19 symptom, whether or not they are presumed to have immunity to SARS-CoV-2. Mildly Ill Patients Antibody testing is not required in mildly ill patients. In patients with no history of COVID-19 infection or having received a full recommended schedule of vaccination, casirivimab + imdevimab at a dose of 1200 mg IV or subcutaneous (SC) OR sotrovimab at a dose of 500 mg IV is recommended if patients have confirmed, symptomatic COVID-19 AND are within 7 days of onset of any COVID-19 symptom AND have at least one of the following risk factors: age > 50, indigenous (First Nations, Inuit, or Metis), obesity, cardiovascular disease (including hypertension), chronic lung disease (including asthma), chronic metabolic disease (including diabetes), chronic kidney disease, chronic liver disease, immunosuppression, or receipt of immunosuppressants. In patients with a history of COVID-19 infection or who have received a full recommended schedule of vaccination, casirivimab + imdevimab at a dose of 1200 mg IV or SC OR sotrovimab at a dose of 500 mg IV may be considered if patients have confirmed symptomatic COVID-19 AND are within 7 days of onset of any COVID-19 symptom AND are immunocompromised or are taking immunosuppressant medications. In patients with a history of COVID-19 infection or who have received a full recommended schedule of vaccination with risk factors other than immunocompromise or immunosuppression, anti-SARS-CoV-2 monoclonal antibodies (AmAbs) are not recommended as these patients have presumed immunity. In patients with no risk factors, AmAbs are not recommended as these patients are at low risk of adverse outcomes. Post-Exposure Prophylaxis (PEP) Casirivimab + imdevimab at a dose of 1200 mg IV or SC OR sotrovimab at a dose of 500 mg IV is recommended for unvaccinated individuals who are currently hospital in-patients or residing in congregate settings (e.g., long-term care settings, retirement homes, shelters, correctional facilities) who have had a high-risk exposure to SARS-CoV-2 (as determined by an expert in Infection Prevention and Control or Public Health) and who are at high-risk to progress to moderate or severe COVID-19. Determination of using an AmAb for post-exposure prophylaxis should take into account the nature and context of their exposure. Implementation Considerations It is recommended that AmAb therapy be administered to non-hospitalized individuals across Ontario using a hybrid network that includes – but is not limited to – mobile integrated healthcare (MIH) services, community paramedicine (CP), and outpatient infusion clinics. Experience from other jurisdictions suggests that hybrid administration approaches coupled with substantial health care system coordination are required to deliver AmAbs in a timely and equitable fashion to those who are likely to benefit from them. Ontario’s supply of AmAbs is limited, and demand by eligible patients may exceed supply in the near future. Understanding the impact of these agents on patient- and system-important outcomes will ensure that they are used equitably and to greatest benefit. There are clear barriers to allocating AmAbs ethically and equitably. A number of strategies are suggested to address these barriers, including optimization of dosing, distribution, supply, administration, allocation, dashboarding, and application of an evidence-informed risk framework for patient selection.
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 |  October 26, 2021

Behavioural Science-Informed Strategies for Increasing COVID-19 Vaccine Uptake in Children and Youth

Using evidence from other successful childhood vaccination programs and from behavioural science, we identify four broad evidence-based strategies for increasing COVID-19 vaccination uptake in children and youth: 1) School-based vaccination, 2) Healthcare provider recommendation, 3) Reminders and recall systems, and 4) Public health communication campaigns. Across each intervention, behavioural science principles can be used to optimize COVID-19 vaccination uptake amongst children and youth including leveraging recommendations from trusted sources; tailoring messaging and experience to children, youth, and their parents/caregivers through individual and population-based approaches; and ensuring special considerations for reaching at-risk and racialized communities.
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 |  October 18, 2021

Evidence-Based Use of Therapeutics for Ambulatory Patients with COVID-19

Clinical trials have improved our understanding of which treatments do and do not help patients with COVID-19. Recommended therapies are based on a careful evaluation in randomized controlled trials (RCTs) to establish that their benefits outweigh any harms, while non-recommended therapies either have demonstrable harm or lack sufficient evidence from randomized trials to warrant their use. There are currently no therapies routinely recommended for mildly ill patients with COVID-19, defined as those not on supplemental oxygen; only supportive care should be provided. These non-recommended therapies include: azithromycin, bamlanivimab, colchicine, hydroxychloroquine, ivermectin, lopinavir-ritonavir, and vitamin D. However oral dexamethasone 6 mg daily (for up to 10 days) is recommended for patients requiring home- or residence-based oxygen therapy. The monoclonal antibodies casirivimab + imdevimab 1200 mg intravenous or subcutaneous, or sotrovimab 500mg intravenous are recommended for mildly ill patients with no history of COVID-19 infection or full vaccination as described in another Science Brief. Though current evidence does not support inhaled corticosteroids having any effect on disease course or serious disease outcomes, inhaled budesonide 800 mcg twice daily for 14 days may be considered in selected patients, as it may reduce patient- reported symptoms and time to recovery.
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 |  October 9, 2021

COVID-19 Vaccine Confidence in Ontario and Strategies to Support Capability, Opportunity, and Motivation Among at Risk Populations

Overall confidence in COVID-19 vaccines amongst Ontarians has remained within the range of 72% to 76%. It is important to understand which individuals and groups have lower vaccine confidence, and why, as this knowledge can support a tailored and informed response. Survey data from 28,660 Ontarians reveal that individuals with lower confidence in COVID-19 vaccines tend to have a lower household income, are more likely to be unable to work from home, and self-identify as racialized (a race other than white European). Lower vaccine confidence is associated with a complex set of factors including health inequities, systemic barriers to accessing health care, and mistrust in government and health care institutions. Community-level strategies, outreach, and interventions can address the drivers of lower vaccine confidence. These strategies include engagement with local leaders, and partnerships with trusted individuals and organizations to build confidence and drive increased vaccine uptake.
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 |  October 7, 2021

Burnout in Hospital-Based Healthcare Workers during COVID-19

Burnout is an occupational hazard in healthcare, which harms the healthcare system, patients, and healthcare workers. In the COVID-19 pandemic, burnout has increased to levels that pose a threat to maintaining a functioning healthcare workforce. Elevated burnout and other indicators of stress are anticipated to persist long after the pandemic. The COVID-19 pandemic has created a cycle of understaffing alongside difficult work conditions which can drive burnout. Robust interventions to bolster individuals, improve work environments and address health system drivers of burnout are important to maintain and support hospital-based healthcare workers. Interventions need to target those most at risk and affected by burnout: nurses, intensive care unit and emergency department staff, women, recent graduates and trainees. Interventions to reduce burnout need to be implemented at organizational and structural level of healthcare systems, complemented by intervention at the individual level. Further, leadership is a vital enabler to address burnout from organizational leaders and managers as well as policymakers. Organizations need to ensure adequate staffing through ongoing evaluation of workload including mitigation of data entry and administrative burdens, efforts to reduce overtime and avoid long shifts, and staff deployment in areas where they lack training. Approaches to mitigate, reduce and address burnout should be multi-faceted and include interventions to improve workplace conditions by fostering a supportive culture, relationships and leadership, as well as individual-level interventions (e.g., education, stress reduction tools, access support for moral distress).
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 |  September 30, 2021

Evidence-Based Recommendations on the Use of Casirivimab + Imdevimab, and Sotrovimab for Adults in Ontario

Critically and Moderately Ill Patients In clinically unstable patients with no history of COVID-19 infection or full vaccination, casirivimab + imdevimab at a dose of 8000 mg IV is recommended if patients are within 9 days of onset of any COVID-19 symptom AND have demonstrated rapid clinical deterioration. Antibody testing is not required in this case. In clinically stable patients with or without a history of COVID-19 infection or full vaccination, casirivimab + imdevimab at a dose of 8000 mg IV may be considered if patients are within 9 days of onset of any COVID-19 symptom AND are not at risk of acute decompensation AND if COVID-19 anti-spike antibody testing demonstrates that they are seronegative. Casirivimab + imdevimab is not recommended for moderately/critically ill patients who are beyond 9 days of onset of any COVID-19 symptom, whether or not they are presumed to have immunity to SARS-CoV-2. Mildly Ill Patients Antibody testing is not required in mildly ill patients. In patients with no history of COVID-19 infection or full vaccination, casirivimab + imdevimab at a dose of 1200 mg intravenous (IV) or subcutaneous (SC) is recommended if patients have confirmed, symptomatic COVID-19 AND are within 7 days of onset of any COVID-19 symptom AND have at least one of the following risk factors: age > 50, obesity, cardiovascular disease (including hypertension), chronic lung disease (including asthma), chronic metabolic disease (including diabetes), chronic kidney disease, chronic liver disease, immunosuppression, or receipt of immunosuppressants. In patients with a history of COVID-19 infection or full vaccination, casirivimab + imdevimab at a dose of 1200 mg IV or SC may be considered if patients have confirmed symptomatic COVID-19 AND are within 7 days of onset of any COVID-19 symptom. In patients with a history of COVID-19 infection or full vaccination with risk factors other than immunocompromise or immunosuppression, SARS-CoV-2 neutralizing antibodies are not recommended as these patients have presumed immunity. In patients with no risk factors, SARS-CoV-2 neutralizing antibodies are not recommended as these patients are at low risk of adverse outcomes. At this time, for mildly ill patients, casirivimab + imdevimab 1200mg IV or SC is preferred over sotrovimab 500mg IV due to practical considerations (i.e. it can also be administered subcutaneously). Ontario’s supply of SARS-CoV-2 neutralizing antibodies is limited, and demand by eligible patients may exceed supply in the near future. Understanding the impact of these agents on patient and system important outcomes will ensure that they are used to greatest benefit. There are clear barriers to allocating SARS-CoV-2 neutralizing antibodies ethically and equitably. A number of strategies are suggested to address these barriers, including optimization of distribution, supply, administration, and allocation, dashboarding, and application of an evidence-informed risk framework for patient selection.
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 |  September 14, 2021

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

The “post COVID-19 condition” (or long COVID) describes a range of symptoms which can persist for months after severe, mildly symptomatic or asymptomatic SARS-CoV-2 infection. The most common of more than 200 reported symptoms include fatigue, shortness of breath, pain, sleep disturbances, anxiety, and depression. Many people with the post COVID-19 condition have difficulty returning to baseline levels of function and have high rates of health care utilization. A conservative estimate suggests that 57,000 to 78,000 Ontarians have or are currently experiencing the post COVID-19 condition, although prevalence estimates can vary widely depending on the case-definition applied. Vaccination is likely protective against development of the post COVID-19 condition. More research is required to develop a consensus definition of the post COVID-19 condition, understand risk factors including the role of viral variants, quantify the impact on specific populations such as children, and develop strategies for prevention and treatment.
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 |  September 13, 2021

The Incidence, Severity, and Management of COVID-19 in Critically Ill Pregnant Individuals

The rate of SARS-CoV-2 infection in pregnancy does not appear to be higher than in the general population; however, compared to their non-pregnant counterparts, pregnant individuals have higher morbidity and mortality, with a higher risk of intensive care unit (ICU) admission, mechanical ventilation, and need for extracorporeal membrane oxygenation (ECMO). They also have a higher frequency of pre-eclampsia, Cesarean delivery, and a higher rate of preterm birth. Care of the critically ill pregnant patient with COVID-19 requires a multidisciplinary team that includes obstetrics, neonatology, anesthesia, infectious diseases, medicine, and critical care. Potentially life-saving evidence-based therapies such as corticosteroids and tocilizumab should not be withheld from pregnant individuals with severe COVID-19. Vaccines against SARS-CoV-2 are safe to use among pregnant individuals and vaccination is highly recommended in this population.
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 |  September 8, 2021

The Impact of the COVID-19 Pandemic on Opioid-Related Harm in Ontario

Rates of opioid-related harms, particularly fatal overdose, have increased significantly in Ontario during the COVID-19 pandemic and have disproportionately impacted marginalized and racialized populations. Strategies to address this crisis include ensuring uninterrupted and equitable access to addiction, mental health, and harm reduction services; incorporating these services into high-risk settings such as shelters, hotels, and encampments; adapting harm reduction services to meet current needs; and promoting access to alternative service delivery methods such as telemedicine programs when in-person services are not available. Leveraging Ontario’s capacity to monitor rates of opioid-related harms can help optimize public health strategies. Data gaps on disparities for those disproportionately impacted by the opioid overdose crisis need to be addressed to improve our understanding of the effectiveness of interventions and guide implementation in high-risk populations.
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 |  September 3, 2021

Heparin Anticoagulation for Hospitalized Patients with COVID-19

Critically Ill Patients Prophylactic dose low molecular weight or unfractionated heparin are recommended in critically ill patients hospitalized with COVID-19. These patients should not receive therapeutic dose anticoagulation unless they have a separate indication for this treatment. Therapeutic dose anticoagulation in this patient population does not reduce the need for organ support and may increase bleeding events as compared to prophylactic dose anticoagulation. Moderately Ill Patients Therapeutic dose low molecular weight or unfractionated heparin may be considered over prophylactic dose anticoagulation in moderately ill patients who are felt to be at low risk of bleeding. All other patients should receive prophylactic dose anticoagulation, unless they have a separate indication for therapeutic dose anticoagulation. Therapeutic dose anticoagulation may reduce the need for organ support (including the need for high-flow nasal oxygen) and appears to decrease thrombotic events in moderately ill patients compared to lower intensity anticoagulation. Its benefits on survival are unclear, and it may increase major bleeding events. Given the small absolute risk reduction for patient-important outcomes and the known harms, a strong recommendation for therapeutic dose anticoagulation in moderately ill patients cannot be made. Mildly Ill Patients There is insufficient evidence to make a recommendation around anticoagulation for mildly ill patients.
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 |  August 26, 2021

The Role of Wastewater Testing for SARS-CoV-2 Surveillance

Wastewater testing for SARS-CoV-2 is relatively new; however, it builds on existing public health surveillance infrastructure. There is a limited but growing evidence base for its use, despite notable interpretation challenges. Wastewater testing results have helped to inform public health policy and interventions during the COVID-19 pandemic in Ontario and other jurisdictions. Wastewater testing for SARS-CoV-2 is useful for early detection of outbreaks and surges as well as population-wide surveillance of COVID-19 that is complementary to clinical testing. Further, it offers an efficient means of SARS-CoV-2 surveillance for specific settings such as correctional facilities, shelters, and university residences. Wastewater testing can also be used for the detection and monitoring of variants of concern (VOCs).
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