August 19, 2020

Dear Colleagues,

Back to school, testing, clearance ...

We are now in the last weeks of summer and, given the return to school, we will be seeing more viral respiratory illnesses. COVID testing will most likely be required for children with the “usual” runny nose, fever, sore throat (among other symptoms on the Reference Document for Symptoms) in order to see if this return to school is resulting in increased incidence of COVID. This short slide deck, written by family physician Dr. Dana Abenstein and educator Darren Abenstein, has helpful tips for parents with return to school.

If a person has symptoms, they should stay at home, and may return 24 hours after symptoms have cleared (if a negative COVID test). If a person has unprotected contact with a POSITIVE CASE, they will need to self isolate for 14 days. See this more detailed Testing and Clearance reference. As with everything COVID, this situation may change but it will be prudent to test symptomatic people, even if your clinical impression would suggest it is “just a cold”. 

Join us on Friday, August 21, 8 to 9 a.m. ET, for the UofT DFCM/OCFP COVID-19 Community of Practice where more ideas will be shared. Guest speakers Dr. Jeff Kwong, a family physician expert in influenza, and Dr. Jennifer Bondy, President of the Essex County Medical Society, will join Dr. David Kaplan and me to answer many questions about the challenges we foresee for the fall.  

FLU shots

Many offices are planning for this upcoming need according to their individual settings – dedicating full days for just flu shot clinics, joining with others, and drive-through flu shot clinics are some approaches.

What to do about IN-PERSON visits for Febrile Respiratory Illnesses (FRI)

• Telephone screen as per previous guidance and refer for testing/assessment at either local assessment centre or Emergency room as clinically indicated. Of note, Ontario Health is currently working with the 145 assessment centres on a new approach to testing – one that targets specific areas of outbreaks and high risk, and also builds testing capacity. Some assessment centres will be offering only swabbing, and we continue to advocate for all these centres having the capacity for assessing as well as swabbing. 
• Conduct in-person follow up if patient tests negative for COVID and you feel an in-person assessment is warranted – for instance, for a new or worsening non-emergent condition that cannot be adequately managed virtually. 
• When seeing patients with a Febrile Respiratory Illness, use appropriate contact and droplet precautions and implement office flow for minimal contact with the patient and other patients and staff.

Sick note requests as the school year approaches

There is a difference between a sick note for someone who is currently SICK, versus a note about a condition that could require workplace accommodation. As we work with our Ontario partners on developing guidance, anticipated shortly, we note this information from the College of Physicians and Surgeons of Saskatchewan reinforcing that a physician’s duty is to report on current illness, and that any need for workplace accommodation rests with the employer.

Here is a list of who is currently considered as high risk from Public Health Ontario. This is very inclusive, so you will need to use your clinical judgement about the severity of the chronic illness. To reiterate, accommodation is the responsibility of the employer.

The OCFP will share more information on this issue as Ontario guidance is finalized.

Testing update

PCR testing

Nasopharyngeal swab PCR preferred, but throat swab acceptable.

- Asymptomatic: as the province prepares for increased testing needs in the fall, testing guidance has been updated. Asymptomatic patients should be considered for testing IF they have had contact with a confirmed case or IF DIRECTED by public health (e.g., visitors to any LTC/retirement home).
- Contact testing: median incubation is still thought to be 5-7 days, but even if negative after unprotected close contact,the person should remain in self-isolation for 14 days after exposure to the case.
- COVID Alert app:the Canadian government’s app for contact tracing can let people know of any possible exposures before any symptoms occur. Please let your patients know about this.
- Transfers: In general, asymptomatic individuals who have previously had a laboratory-confirmed case of COVID-19 and have since recovered do NOT require testing prior to or after transfer between facilities unless they have had a new high-risk exposure or become symptomatic.
- Teachers: testing if symptomatic or if contactwith confirmed case.

 Serology testing

 Serology should NOT be used for screening and diagnosis of acute COVID-19 infection unless:

- Children suspected of Multisystem Inflammatory Syndrome if PCR is negative;
- Patients with severe illness who have tested negative for COVID-19 by PCR and where serology testing would help inform clinical management and/or public health action.

Mask use

Exemptions for mask use need to be for a restricted number of indications. In Ontario, these are:

- Children under the age of two;
- Anyone who has trouble breathing (note: currently, this is not consistent with guidance from the Canadian Thoracic Society, who say “We recognize that wearing a face mask may not be possible for some people, but their lung disease should rarely be the cause of this.”);
- Anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance.
Here is a link to a video that helps patients with “mask anxiety”. 

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Family physicians play such an important frontline role in protecting and promoting the health of our population. We know we often need to see our patients in person. Inherent in being in health care is a degree of risk to our own health which we must learn to mitigate through infection control practices that make sense and are applied consistently.

The tragic death of Dr. Walter Reynolds in Red Deer, Alberta – by all accounts an outstanding physician and human being – is a sad reminder of another danger our frontline work can bring, and the unfortunate need to think of safety design and alerts in our offices. 

I hope you have all had a chance to take time with family and friends, recharging for the essential work that you do in your professional lives. 

Yours in family medicine,

Jennifer