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  • Science Brief (124)
    • Health Equity & Social Determinants of Health (8)
    • Infectious Diseases & Clinical Care (47)
    • Public Policy & Economic Impact (7)
    • Epidemiology, Public Health & Implementation (62)
  • COVID-19 (142)
  • H1N1 influenza (6)

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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Published: December 9, 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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Published: November 24, 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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Published: October 18, 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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Published: October 7, 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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Published: September 30, 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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Published: September 3, 2021
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