Hastings Prince Edward Public Health
Online Bulletin for Health Care Providers

October 17, 2022

From:
Dr. Ethan Toumishey
Medical Officer of Health and CEO
Hastings Prince Edward Public Health

In this Issue:

  1. Health Care Providers encouraged to order influenza vaccine as soon as possible
  2. UPDATE: Evusheld Expanded Access and Eligibility for COVID-19 Prevention
  3. Reminder: Paxlovid for COVID-19 Treatment
  4. COVID-19 Boosters - What advice should health care providers be giving patients?
  5. UPDATE: COVID-19 Guidance for Long-Term Care Homes, Retirement Homes and Other Congregate Living Settings
  6. Monkeypox
  7. UPDATE: Botulism Guide for Health Care Professionals

  8. UPDATE: Arbovirus (non-Zika) Testing

News & Updates

Health Care Providers encouraged to order influenza vaccine as soon as possible

HPEPH is urging health care providers to order influenza vaccine as soon as possible, to begin administering to your high-risk patients/clients immediately. The general population will become eligible for influenza vaccine once the annual influenza campaign is officially launched by the Ministry of Health. All high-risk clients/patients are eligible for influenza vaccination at the current time.

As we anticipate a very challenging respiratory virus season, it is critical that individuals are provided with the opportunity to receive this vaccine through their health care provider. For ordering and pick up information, please view this memorandum (Originally sent September 15, 2022 via fax/email).

We look forward to receiving your order and working together to prevent the spread of influenza in our region this respiratory season.

UPDATE: Evusheld Expanded Access and Eligibility for COVID-19 Prevention

Evusheld is a prophylactic monoclonal antibody therapy authorized by Health Canada in April 2022 for the prevention of COVID-19 in severely immunocompromised adults and children 12 years of age and older.

In Ontario, Evusheld can be administered to individuals with the highest risk of a severe outcome from COVID-19, including:

  • solid organ transplant recipients;
  • stem cell transplant recipients;
  • CAR-T therapy recipients; and
  • other hematologic cancer patients undergoing treatment;
  • people receiving anti-B-cell therapy (e.g., rituximab) (new as of October 2022)
  • people with significant primary immunodeficiency (new as of October 2022)

Access to Evusheld

There are various pathways to access Evusheld available to health care providers and patients. Health care providers who may be prescribing or administering Evusheld through these pathways should review Information about Evusheld (Tixagevimab and Cilgavimab) for more information.

  • Evusheld continues to be offered through select hospital-based clinics, including cancer and transplant programs, and some clinical assessment centres. Some clinics may accept referrals from providers in the community (check with the Ontario Health regional contact below).

  • NEW Effective October 3, 2022: Evusheld can be dispensed through pharmacies

    • Physicians and nurse practitioners can prescribe the drug for pickup at a local pharmacy, with administration (i.e., injection) completed by the prescribing clinician or an appropriate health care provider. Note that prescriptions for Evusheld may not be available for pick up the same-day, as pharmacies are likely to place orders for Evusheld upon receipt of a prescription (1–2 day turnaround).

    • Evusheld requires refrigeration storage (2°C – 8°C) and appropriate cold chain must be maintained.

    • Pharmacies can dispense 300 mg or 600 mg doses (must be specified on the prescription).

All prescribers who administer Evusheld will need to obtain patient consent and file a report with their local Public Health Unit as soon as possible to allow for entry into the COVAxOn reporting system. A consent and reporting template is available here.

Questions about Evusheld should be directed to your Ontario Health regional contact:

More information: Patient handout on Evusheld

Reminder: Paxlovid for COVID-19 Treatment

Paxlovid is an antiviral medication that may be prescribed to your patients at highest risk of developing severe symptoms of COVID-19. Paxlovid is free for all people living in Ontario with a prescription from their HCP.

Health care providers are encouraged to prescribe Paxlovid to patients at highest risk of severe COVID-19 symptoms. These individuals include:

  • immunocompromised
  • 70 and older
  • 60 and older with less than three vaccine doses
  • 18 and older with less than three vaccine doses and at least one of the following risk conditions:
    • obesity
    • diabetes
    • heart disease
    • hypertension
    • congestive heart failure
    • chronic respiratory disease (including cystic fibrosis)
    • cerebral palsy
    • intellectual or developmental disability
    • sickle cell disease
    • moderate or severe kidney disease
    • moderate or severe liver disease
    • pregnancy

More Information:

 

COVID-19 Boosters - What advice should health care providers be giving patients?

*Sharing from Toronto Public Health*

Dr. Allison McGeer shared her knowledge in answering this question to Toronto Public Health. Dr. Allison McGeer is a Microbiologist & Infectious Disease Consultant at Sinai Health System. She is also the Principal Investigator of The Toronto Invasive Bacterial Diseases Network, and a Professor of Laboratory Medicine at the University of Toronto.

What is happening to COVID-19 activity now?
For the 6-8 weeks until the first week of October, cases, hospitalizations and deaths have been holding steady or declining slightly.1 There are, however, two important caveats to being complacent about this.

  • The first is that, if nothing changes, about 2600 Ontarians will die of COVID-19 in the next 12 months,1 a death rate about twice that of regular influenza season,2 and making COVID-19 the 7th leading cause of death.3 While there is no question this is a major improvement in the pandemic (COVID-19 was the third leading cause of death in Canada in 2020 despite the lockdowns), there is still very good reason to continue to advocate strongly for booster doses of vaccine, our most effective way to mitigate this on-going impact.
  • The second is that, as expected with colder weather, return to work and school, waning immunity from previous infection and vaccine doses, and low booster uptake to date, the waste-water signals may be starting to increase in Ontario,4 and this week, outbreaks in long-term care in Toronto have increased.5 Increasing hospitalizations are being seen across many jurisdictions in North America and Northern Europe.6 While we can reasonably hope that the wave will not be too large, it appears likely that another wave of activity is starting. Getting booster doses of vaccine into arms now will prevent a significant amount of serious illness and death.7
     

Who should be getting boosters?
NACI recommends that anyone who is 65 years of age and over, or is 12-64 years old and has a underlying chronic condition or situation predisposing to severe COVID-19 should get a booster dose this fall.8 Children aged 5 years and under are not recommended for a booster. For everyone else – including most 12-64 year olds, a booster dose is a choice - similar to the choice about getting an influenza vaccine. For these children and adults, the risk of hospitalization and death is present, but now very low. So the decision about getting the vaccine is about balancing the risks of COVID-19 against the risk associated with vaccines. Thinking about the risk of COVID-19 includes:

  • assessing the risk of infection or re-infection (for instance, regular or anticipated exposure to international travel, which substantially increases the risk of exposure; or work in healthcare or a service industry that requires exposure to many people in indoor environments),
  • the consequences of infection (if you need to take 3-5 days off for illness, how much does this matter?), and the risk that you might expose others who are more vulnerable (e.g. older family members, colleagues or friends with immunocompromising conditions or cancer).
  • Balanced against these risks of COVID-19, are the time it takes to get a vaccine, and the short term “reactogenicity” – the fever and feeling unwell for a few days that may accompany vaccination.
     

Which booster should people get?
Two bivalent (meaning, containing 2 different strains of SARS-CoV-2) boosters are now authorized and available in Canada:

  • a Moderna vaccine that has the original strain and a BA.1/2 strain, and
  • a Pfizer vaccine that has the original strain and a BA.4/5 strain.8

As most infections are now due to BA.4 or BA.5 strains, there is a tendency to think that the Pfizer bivalent vaccine is preferred. In fact, however, the evidence is that there is very little difference in the protection against COVID-19 afforded by these two vaccines. Moderna has a higher concentration of antigen than Pfizer, and is a significantly more efficacious vaccine than Pfizer.9-11 Thus, the Moderna BA1.2 vaccine is likely to be as or almost as efficacious against BA4.5 as the lower concentration Pfizer vaccine. The data we have so far suggests that any difference in vaccine efficacy against severe disease would be less than 1% and any difference between any symptomatic infection would be less than 5% (e.g. 65% vs. 60%).12 In the slightly longer term, we don’t know what new variant is going to dominate. If it is a BA.4/5 variant then the BA.4/5 variant vaccines may be marginally better; if it is a BA/1.2 then the BA.1/2 variant vaccines may be marginally better; if it is a recombinant virus, they may be equally effective. NACI recommends that anyone getting a booster this fall should get one of these bivalent vaccines.8

References:

  1. Public Health Ontario. COVID-19 Weekly Epidemiology Report. Available at:https://www.publichealthontario.ca/-/media/Documents/nCoV/epi/covid-19-weekly-epi-summary-report.pdf?sc_lang=en.
  2. Schanzer DL, Sevenhuysen C, Winchester B, Mersereau T. Estimating influenza deaths in Canada, 1992-2009. PLoS One. 2013 Nov 27;8(11):e80481. doi: 10.1371/journal.pone.0080481.
  3. Statistics Canada: Deaths and age-specific mortality rates, by selected grouped causes. Available at: https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310039201.
  4. Public Health Ontario. COVID-19 Wastewater Surveillance in Ontario. Available at: https://www.publichealthontario.ca/en/Data-and-Analysis/Infectious-Disease/COVID-19-Data-Surveillance/Wastewater
  5. Toronto Public Health. Outbreaks in Toronto Healthcare Institutions. Available at: https://open.toronto.ca/dataset/outbreaks-in-toronto-healthcare-institutions/
  6. Our World in Data. COVID-19 weekly hospital admissions. Available at: https://ourworldindata.org/coronavirus#explore-the-global-situation; see also https://www.ctvnews.ca/health/coronavirus/covid-tracker, and https://www.nytimes.com/interactive/2021/us/covid-cases.html
  7. Link-Gelles R, Levy ME, Gaglani M, Irving SA, Stockwell M, Dascomb K, et al. Effectiveness of 2, 3, and 4 COVID-19 mRNA Vaccine Doses Among Immunocompetent Adults During Periods when SARS-CoV-2 Omicron BA.1 and BA.2/BA.2.12.1 Sublineages Predominated - VISION Network, 10 States, December 2021-June 2022. MMWR Morb Mortal Wkly Rep. 2022 Jul 22;71(29):931,939. doi: 10.15585/mmwr.mm7129e1
  8. National Advisory Committee Statement. Updated guidance on COVID-19 vaccine booster doses in Canada, October 7, 2022. https://www.canada.ca/content/dam/phac-aspc/documents/services/immunization/national-advisory-committee-on-immunization-naci/guidance-covid-19-vaccine-booster-doses.pdf
  9. Dickerman BA, Gerlovin H, Madenci AL, et al. Comparative Effectiveness of BNT162b2 and mRNA-1273 Vaccines in U.S. Veterans. N Engl J Med. 2022;386:105-115. doi: 10.1056/NEJMoa2115463.
  10. Abu-Raddad LJ, Chemaitelly H, Ayoub HH, et al. Effect of mRNA Vaccine Boosters against SARS-CoV-2 Omicron Infection in Qatar. N Engl J Med. 2022;386:1804-1816. doi: 10.1056/NEJMoa2200797.
  11. Mues KE, Kirk B, Patel DA et al. Real-world comparative effectiveness of mRNA-1273 and BNT162b2 vaccines among immunocompromised adults identified in administrative claims data in the United States. Vaccine. 2022:S0264-410X(22)01120-3. doi: 10.1016/j.vaccine.2022.09.025.
  12. Khoury DS, Docken SS, Subbarao, K, et al. Predicting the efficacy of variant-modified COVID-19 vaccine boosters. medRxiv 2022.08.25.22279237; doi: https://doi.org/10.1101/2022.08.25.22279237

Additional COVID-19 Vaccine Resources for Health Care Providers

UPDATE: COVID-19 Guidance for Long-Term Care Homes, Retirement Homes and Other Congregate Living Settings

The Ministry of Health has updated the COVID-19 Guidance for Long-Term Care Homes, Retirement Homes and Other Congregate Living Setting – Version 8 – October 3, 2022.

Highlights of changes include :

  • Updated to include other congregate living settings
  • Roles and responsibilities clarified
  • Updates to screening guidance
  • Further clarification provided for PPE requirements
  • Updates to admissions/transfers requirements
  • Updated outbreak definition
  • Updates to contact management and outbreak management

Long-Term Care Homes: UPDATED COVID-19 Guidance Document for Long-Term Care Homes in Ontario

As of October 14, 2022, the following changes have been made to this document:

  • Screening requirements have shifted from active to passive screening to embed this practice into the regular practices of long-term care homes aimed at reducing the risk of infectious respiratory illnesses within homes. Active screening for visitors and caregivers continues to be recommended.
  • While masks continue to be required for long-term care staff, as well as for visitors and others entering long-term care homes, masks while recommended are no longer required when visitors or caregivers are alone with a resident in their room.
  • Physical distancing requirements have been updated to align with other high-risk settings. Physical distancing continues to be encouraged and residents continue to be urged to avoid situations like crowded places where COVID-19 can spread more easily
  • Long-term care homes can return to regular practice for setting their own visitor policy. The provincially set limit of 4 visitors (including caregivers) per resident at a time for indoor visits has been removed.
  • Daily screening of residents for signs and symptoms of COVID-19 and screening of residents upon return from an absence continues to be required, but testing of residents is not longer required unless they have symptoms.

Retirement Homes: UPDATED Ministry for Seniors and Accessibility COVID-19 Guidance Document for Retirement Homes in Ontario

More information on the updates can be found in the October 6, 2022 COVID-19 Updates for Retirement Home Sector memo and include :

  • Screening - Although active screening is still recommended for visitors, operators may shift to passive screening for staff, students, and volunteers.
  • Absences - Residents will no longer be required to test upon return from temporary absences.
  • Masking - While masking continues to be strongly recommended, all visitors will be able to remove their mask while in a resident’s room.
  • Physical Distancing - Retirement homes are no longer required to implement physical distancing (e.g., a minimum of 2m or 6ft between individuals); however, they should continue to adjust activities to optimize and support physical distancing where possible.

Monkeypox

At the current time, there continues to be no lab confirmed cases of monkeypox virus within Hastings or Prince Edward counties. Ontario has reported 674 lab confirmed cases as of October 4th with evidence of new case reports continuing to decline. Refer to Public Health Ontario’s Epidemiological Summary on Monkeypox in Ontario for more information.

UPDATE: Monkeypox Vaccine Expanded Eligibility

The Ministry of Health has updated the Monkeypox Vaccine (Imvamune®) Guidance for Health Care Providers to reflect expanded 1st and 2nd dose eligibility for Imvamune® (see page 2 for the full list of eligibility criteria).

  • The Ministry of Health continues to recommend that immunization using the Imvamune® vaccine should be offered to individuals with the highest risk of monkeypox.
  • First dose eligibility has been expanded and the following individuals are now eligibile:
    • Two-spirit, non-binary, transgender, cisgender, intersex or gender-queer individuals who self-identify as belonging to the gay, bisexual, pansexual and other men who have sex with men (gbMSM) community and had a confirmed sexually transmitted infection within the last year
  • Everyone eligible to receive Imvamune® as pre-exposure prophylaxis can now receive a second dose with a minimum spacing of 28 days

Those that received a single dose of Imvamune® as post-exposure prophylaxis may receive a second dose if the risk of exposure continues beyond or is expected to continue beyond 28 days following their first dose

UPDATED Monkeypox Guidance Documents:

For more information:

UPDATE: Botulism Guide for Health Care Professionals

On October 7th, the Ministry of Health released a memo to public health units providing updated information and considerations for ordering BabyBIG to treat Infant Botulism. This has been reflected in updates to the Botulism Guide for Health Care Professionals and Infectious Disease Protocol Botulism Appendix 1.

Updates:

  • Health Canada’s Special Access Program (SAP) requires that available marketed products in Canada be considered when a review is conducted during the ordering of BabyBIG to treat Infant Botulism. The marketed product in Canada (product monograph for Botulinum Anti-toxin (BAT)) has a recommended dose for infants
    • The Botulism Guide for Health Care Professionals has been updated to reflect the requirements for review of available products per the SAP process and considerations.

The initial diagnosis of botulism should be based on a history of recent exposure, consistent clinical symptoms and elimination of other illnesses in the differential. All treatment and management decisions should be made based on clinical diagnosis.

UPDATE: Arbovirus (non-Zika) Testing

Specimens submitted for arbovirus (non-Zika), testing must be accompanied by a completed mandatory Arbovirus (Non-Zika) Testing Intake Form and a separate PHO Laboratory General Test Requisition for each specimen type collected, e.g. serum, CSF. Failure to provide the required information may result in rejection or delays in appropriate test assignment.

Note:

  • If ordering West Nile virus serology only, the Arbovirus (Non-Zika) Testing Intake form is not required.
  • For Zika testing, complete the Zika Mandatory Intake Form, NOT the Arbovirus (Non-Zika) Testing Intake form.

The Arbovirus (non-Zika) Testing Intake Form must be filled for all arbovirus test requests, except West Nile virus and Zika virus. Examples of such arboviruses include:

  • West Nile virus (PCR requests only)
  • California serogroup viruses
  • dengue virus
  • eastern equine encephalitis virus
  • Japanese encephalitis virus
  • Powassan virus
  • Ross River virus
  • tick-borne encephalitis virus
  • Venezuelan equine encephalitis virus
  • western equine encephalitis virus
  • yellow fever virus

For more information: Public Health Ontario Test Information Index

Current information on COVID-19 specifically for health care providers can be found at hpePublicHealth.ca, Ontario Ministry of Health and at publichealthontario.ca.

Back to Summary

Contact Information: 

To report communicable diseases:613-966-5500 x349

To report AEFI or DOPHS: Online / Fax: 613-966-1813 or CDCFAX1@hpeph.ca

Hastings Prince Edward Public Health is situated and provides services on the traditional territory of the Anishinaabe, Huron-Wendat and Haudenosaunee people.

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