Dear Colleagues,

I know first-hand as a family physician practising in Ottawa that it has been an incredibly challenging week; and it is likely now these protests will spread to other regions. I have seen family physicians and all health and social service workers working extremely hard to keep providing care under these difficult circumstances and I am grateful to you. We are ​witnessing real impacts to our patients in their mental and physical health. The OCFP stands behind our members and we support you to be able to do your critical work safely; and we join with others in our hope that this will end soon and peacefully.

At the same time, all of us continue to be busy with the ongoing demands of the pandemic – we’re keeping up with evolving guidance and new COVID treatments, supporting our COVID+ patients at home, catching up on the pandemic backlog, and continuing to see priority patients for other non-COVID care. I am thankful we are also seeing some hopeful signs, including newer options for treating COVID becoming available and gradual resumption of diagnostic imaging, cancer screening and clinics in hospitals, per the just-reissued Directive #2. For as long as needed, the OCFP will continue to provide updates and supports, so that you can continue ensuring safe and needed care to your patients. 

Balancing Demands

• See the OCFP’s updated Considerations for Balancing In-person and Virtual Care and our summary on N95 respirators when seeing COVID-19 patients. With appropriate PPE, patients can be seen safely in person and virtual visits remain an option. 
• The OCFP has also updated our Considerations for Balancing Demands, including more info on caring for symptomatic and COVID +ve patients.
• Continue to prioritize acute, emergent, and new conditions, symptomatic patients at higher risk for severe outcomes from COVID-19 infection (who may be eligible for therapeutics – see below), and preventive care for those at higher risk.
• This may mean longer wait times for some routine care, where the risk to the patient is low – e.g., well child visits not associated with immunization, chronic disease follow-up in stable patients. See this patient script to remind your patients of your need to prioritize and that we will always provide the care they need, when it’s needed.

COVID-19 care at home

• For your symptomatic patients who are at risk of severe illness from COVID-19 infection yet can be managed at home, consider monitoring them yourself with the support of the COVID@Home program. Use this form to order O₂ saturation monitors at no cost. You can also refer them to remote care management programs offered in your community where available; see this Ontario Health list of remote care monitoring teams and referral information.
• Reposting the excellent "one-stop" online resource for managing COVID patients in the community, from Hamilton Family Medicine.
• Upcoming OH webinar on monitoring and management of COVID patients in the community and guidance on post-COVID-19 conditions: February 9 | 8-9 a.m. REGISTER

 Testing

• We understand the shortage of rapid access tests has abated and you can expect any backorders of test kits through the Provincial Pandemic Stockpile to be filled very soon.
• Notable in Ontario’s updated testing strategy, released on Feb. 2:
• Rapid antigen testing recommended for frequent, repeated testing of asymptomatic people with no known exposure – so could apply to screening clinic staff.
• Proof of negative test should not be a requirement for in-person consults.
• OCFP has been advocating and we are pleased to share (just announced) that eligibility for PCR testing has been extended to include symptomatic household members of patient-facing healthcare workers.

 COVID-19 clinical assessment centres | Outpatient therapies

 All recommended COVID-19 therapies are outlined in the latest (Jan 21) Science Advisory Table summary of guidelines for treatments and additional briefs on fluvoxamine and Paxlovid. Note that supplies are currently limited for some treatments.

• In general, for your patients who are at higher risk for severe outcomes (tier 1 or 2 per SAT guidance), sotrovimab and Paxlovid are the first-line options. Note that access may vary by location and there are many drug-drug interactions to be considered. For patients who are tier 3 or 4, consider fluvoxamine and/or budesonide.
• Therapeutics were a focus in the Feb. 4 COVID-19 CoP session. See recording; and here is an excellent patient summary of COVID-19 medications, newly out from ConfusedAboutCOVID.ca.
• New Guidance from Ontario Health outlines how you can access sotrovimab (monoclonal antibody) and the oral antiviral Paxlovid, for your patients at higher-risk for severe infection. See OCFP summary of the OH guidance.
• See general potential pathways to antiviral treatment and note that pathways may vary locally.
• COVID-19 clinical assessment centres (CACs) are the access points for both sotrovimab and Paxlovid. More about CACs in these FAQs and from the Centre for Effective Practice.
• There is a short window for starting therapeutics and a COVID-19 test is required:
  • ïFor sotrovimab and Paxlovid – know who your high-risk patients are, prioritize these patients for appointments or refer them to a CAC if they can’t be seen within 24 hours of seeking support. Here is patient script that you can adapt for your practice and a phone script from OH for clinic staff.
  • Your high-risk patients may also self-refer to a CAC if they answer “yes” to these two questions: 1) do you have COVID symptoms? AND 2) did they start within 7 days?
• Be aware there are numerous serious drug interactions limiting who can receive Paxlovid. More from the Science Advisory Table: guidelines for treatments (Jan. 21, 2022) and Paxlovid information for prescribers and pharmacists.
• Fillable referral form for sotrovimab – referral processes may vary and supplies are limited so contact the clinic first. Note that sotrovimab may be administered through local hospitals in the Ontario Health North region: direct the patient to book at a CAC, if available, or contact the CAC to arrange testing and reach out to the hospital to access treatment if appropriate and available.
• Colleagues at North York Family Health Team have digitized the referral form, available to Telus PS and Accuro users, and Dr. Kevin Lai has created a form for OSCAR. Instructions here.

Vaccination

• Continue to help your patients to access vaccination and offer vaccination, including boosters, if you are able. There has been a slowing of vaccination rates particularly amongst children 5-11 years old, family doctors play a critical role in building parental confidence in vaccination. Re-sharing this list of Public Health Unit contacts if you want to reach out to request vaccines for your office. 
• Pregnant or breastfeeding: The Provincial Council on Maternal and Child Health has updated patient information on COVID-19 vaccination for pregnant and breastfeeding people, including recommendation for booster doses.
• New NACI guidance (Jan. 25) for moderately to severely immunocompromised children 5-11 years old to receive three doses with an interval of 4 to 8 weeks between each dose.  
• New NACI guidance (Jan. 28) for adolescents 12-17 years old at higher risk for severe outcomes from COVID-19, to receive a booster dose at interval of 6 months or longer. Higher risk includes those with underlying medical conditions (for immunocompromised, the booster would be dose 4), residents of congregate living settings, and/or belong to racialized or marginalized disproportionately affected by COVID-19.
• New from NACI (Feb. 4): For vaccinated individuals aged 12 and up who are eligible for a third dose, NACI recommends waiting three months after the onset of symptoms, or following a positive test for anyone who was asymptomatic — while also being at least six months out from a second dose. 
• I was pleased to participate in the OMA’s Feb. 3 town hall on COVID-19 and children, with Dr. Kieran Moore, Ontario’s chief medical officer of health, and other experts. If you missed it live, you can view the recording.

Clearance notes

• For travel: We know you are getting more patient requests for letters to document recovery from COVID-19 as a condition of travel and/or entry. This is a federal matter, tied to the policies of other countries, but we feel strongly we must find ways to minimize this distraction from our core work in patient care. We have raised this issue with federal officials, including a request to Global Affairs Canada to advocate to international colleagues on behalf of Ontario’s family doctors.
• It is the traveller’s responsibility to be aware of the requirements of their airline, destination country and transit countries.
• Note that for U.S. travel, a doctor’s note is not required if the patient provides proof of a negative test result. CDC information
• Below is draft wording for a letter documenting recovery from COVID-19 that you can adapt for your practice, consistent with the CMPA guidance on "recovery notes" when you were not involved in the testing and/or didn't see the patient when they were unwell. 
• For return to school/daycare/work: Doctors’ notes are not required. The OMA has updated its attestation forms which patients can use instead of doctor’s notes.

Documentation of Recovery from COVID-19

[DATE]

This patient provided a history of positive COVID-19 test [SPECIFY TYPE OF TEST] and was diagnosed on [DATE OF TEST AND IF IT WAS DONE AT HOME]. The patient has confirmed that they completed the isolation period required by Ontario provincial guidelines on [DATE].

Based on our assessment today, the patient has no fever and [his/her] symptoms have been improving for at least 24 hours (48 hours for gastrointestinal symptoms).

[SIGNATURE]

 Other updates

• This benefits “wayfinder” has been updated to include COVID-related support programs and may be an especially helpful tool for your patients who have structural vulnerabilities. Patients can also call the 211 helpline for support accessing community and social services.
• See the latest additions and translations to ConfusedAboutCOVID.ca, a series from the OCFP and UofT DFCM, including “My Child Has COVID. What should I know?”
• The COVID-19 Community of Practice, hosted by the OCFP and UofT DFCM, continues to bring together hundreds of our colleagues to help address the most urgent COVID-19 issues for family doctors. Check out all past sessions and register for upcoming sessions.   

A common theme coming out of the livestream sessions of OCFP’s Family Medicine Summit last week was the commitment we have as family doctors to continue to do what it takes to make the system better – better for our profession, for our colleagues, and our patients. Staying connected to the purpose and value of our work as family doctors is an important part of remaining hopeful in this time.  

A second theme was the importance of meaningful connections with colleagues to help us shoulder the burden we have been carrying all through this pandemic. I am thankful for our partners in the Primary Care Collaborative, and our united voice to ensure primary care is supported as the foundation of our healthcare system.

I’ll close by calling your attention to the 2022 OCFP Awards, which are open for nominations until March 13. The OCFP Awards are a perfect way to celebrate our profession in all its diverse facets. Please take the opportunity to nominate a colleague or team of colleagues, or yourself!

Stay well, 

Liz