Health
COVID-19: Canadian hospital space a concern despite lessons from SARS, experts say – Global News
Canadian medical experts say the country’s already overstretched emergency rooms would find it difficult to cope if a true outbreak of the novel coronavirus, or COVID-19, were to take hold in Canada.
So far, the virus has been relatively contained to mainland China, thanks in part to one of the largest quarantines in modern history.
“We must not look back and regret that we failed to take advantage of the window of opportunity that we have now,” Dr. Tedros Adhanom Ghebreyesus, director general of the World Health Organization, said in a message to all the world’s countries Friday.
The risk of contracting the virus in Canada right now is extremely low, and public health officials have been lauded for their efforts to detect and isolate the nine cases confirmed in the country so far.
The hundreds of patients across the country who have tested negative for the virus are also a sign that containment efforts are working as they should.
But Canada’s most recent case in British Columbia has raised fears about where and how the disease is being transmitted abroad. Unlike others who’ve imported the virus from China or from people who have recently been to China, the woman in her 30s contracted the illness while in Iran.
“Any imported cases linked to Iran could be an indicator that there is more widespread transmission than we know about,” said Canada’s chief medical officer Dr. Theresa Tam Friday.
Canada has taken major steps to prevent the kind of shock that befell Ontario during the outbreak of the coronavirus known as SARS in 2003 that led to 44 deaths. Creating the Public Health Agency of Canada, which Tam heads, is one of them.
The country is now better co-ordinated, has increased its lab-testing capabilities and is prepared to trace people’s contacts to find people who might have caught a contagious illness without knowing it.
But once the number of incoming cases reaches a critical mass, the approach must change, according to infectious-diseases physician Dr. Isaac Bogoch of Toronto’s University Health Network.
He likens the response to trying to catch fly balls in the outfield: as the number of balls in the air increases, they become harder and harder to snag.
“Every health care system has limits,” Bogoch says. “The question is, if we start getting inundated with cases, how stretched can we get?”
READ MORE:
With COVID-19 emerging in new countries, health officials worry about untraceable clusters
Many emergency-room doctors argue Canada’s ERs are already as stretched as they can get and are worried about what would happen if they suddenly had to start treating COVID-19 cases en masse.
From the public-health perspective, the greatest challenge may be as simple communicating across all parts of the health system across the country, said Dr. Jasmine Pawa, president of the Public Health Physicians of Canada.
“We cover a very wide geographic area,” she said, though she added that Canada has made great strides over the course of the SARS experience and the H1N1 flu outbreak in 2009.
Dr. Alan Drummond of the Canadian Association of Emergency Physicians, who works at the hospital in Perth, Ont., says he doesn’t want to fearmonger, especially considering all the lessons Canada has learned from past outbreaks, but the reality of life in the ER gives him pause.
“Our day-to-day experience in crowded hospitals, unable to get the right patient in the right bed on a day-to-day basis ? makes us really question what the integrity of our health-care system would be like in a major severe pandemic,” Drummond says.
He envisions that a disease like COVID-19, if it spread widely, would have a major impact, including the possibility of cancelled surgeries and moving stable patients out of hospitals who would otherwise stay.
“I think there would have to be hard decisions made about who lives and who dies, given our limited availability by both speciality and (intensive-care) beds and we would probably see some degree of health-care rationing,” he says.
The problem may be even more pronounced because of Canada’s aging population, he said. The virus tends to hit older people harder, according to observations made in China and abroad, and is also particularly dangerous for people with other health problems.
Older people also tend to stay admitted in hospital beds even when they are in relatively stable condition because of a lack of long-term-care beds across the country.
That keeps emergency rooms from being able to move acute patients out of the ER and into those beds, limiting hospitals’ capacity to handle new cases.
Tam agreed Friday that hospital capacity is a “critical aspect” of Canada’s preparedness for a potential coronavirus outbreak, but said even very bad flu seasons can have a similar effect on emergency rooms.
“If we can delay the impact of the coronavirus until a certain period, when there’s less influenza for example, that would also be very helpful,” she said.
She also suggested people who are concerned about the possibility that they’re developing COVID-19 symptoms should call ahead to a hospital so they can make proper arrangements for containment and isolation.
Canada is doing its best, along with every other country in the world, to seize this time of relative containment and plan ahead, Tam said.
© 2020 The Canadian Press
A business plan for a new BC Cancer Centre at Nanaimo Regional General Hospital has been approved by the province.
Health Minister Adrian Dix says the state-of-the-art cancer facility will benefit patients in Nanaimo and the surrounding region through the latest medical technology.
The facility will have 12 exam rooms, four consultation rooms and space for medical physicists and radiation therapists, medical imaging and radiation treatment of cancer patients.
The procurement process is underway, and construction is expected to begin in 2025 and be complete in 2028.
Upgrades to NRGH have also been approved, such as a new single-storey addition to the ambulatory care building and expanded pharmacy.
Dix says Nanaimo’s population is growing rapidly and aging, and stronger health services in the region, so people get the health care they need closer to home.
Health
Outdated cancer screening guidelines jeopardizing early detection, doctors say – Powell River Peak
A group of doctors say Canadian cancer screening guidelines set by a national task force are out-of-date and putting people at risk because their cancers aren’t detected early enough.
“I’m faced with treating too many patients dying of prostate cancer on a daily basis due to delayed diagnosis,” Dr. Fred Saad, a urological oncologist and director of prostate cancer research at the Montreal Cancer Institute, said at a news conference in Ottawa on Monday.
The Canadian Task Force on Preventive Health Care, established by the Public Health Agency of Canada, sets clinical guidelines to help family doctors and nurse practitioners decide whether and when to recommend screening and other prevention and early detection health-care measures to their patients.
Its members include primary-care physicians and nurse practitioners, as well as specialists, a spokesperson for the task force said in an email Monday.
But Saad and other doctors associated with the Coalition for Responsible Healthcare Guidelines, which organized the news conference, said the task force’s screening guidelines for breast, prostate, lung and cervical cancer are largely based on older research and conflict with the opinions of specialists in those areas.
For example, the task force recommends against wide use of the prostate specific antigen test, commonly known as a PSA test, for men who haven’t already had prostate cancer. Saad called that advice, which dates back to 2014, “outdated” and “overly simplistic.”
The task force’s recommendation is based on the harms of getting false positive results that lead to unnecessary biopsies and treatment, he said.
But that reasoning falsely assumes that everyone who gets a positive PSA test will automatically get a biopsy, Saad said.
“We are way beyond the era of every abnormal screening test leading to a biopsy and every biopsy leading to treatment,” he said, noting that MRIs can be used to avoid some biopsies.
“Canadian men deserve (to) have the right to decide what is important to them, and family physicians need to stop being confused by recommendations that go against logic and evidence.”
Dr. Martin Yaffe, co-director of the Imaging Research Program at the Ontario Institute for Cancer Research, raised similar concerns about the task force’s breast cancer screening guideline, which doesn’t endorse mammograms for women younger than 50.
That’s despite the fact that the U.S. task force says women 40 and older may decide to get one after discussing the risks and benefits with their primary-care provider.
The Canadian task force is due to update its guidance on breast cancer screening in the coming months, but Yaffe said he’s still concerned.
“The task force leadership demonstrates a strong bias against earlier detection of disease,” he said.
Like Saad, Yaffe believes it puts too much emphasis on the potential harm of false positive results.
“It’s very hard for us and for patients to balance this idea of being called back and being anxious transiently for a few days while things are sorted out, compared to the chance of having cancer go undetected and you end up either dying from it or being treated for very advanced disease.”
But Dr. Eddy Lang, a member of the task force, said the harms of false positives should not be underestimated.
“We’ve certainly recommended in favour of screening when the benefits clearly outweigh the harms,” said Lang, who is an emergency physician and a professor at the University of Calgary’s medical school.
“But we’re cautious and balanced and want to make sure that we consider all perspectives.”
For example, some men get prostate cancer that doesn’t progress, Lang said, but if they undergo treatments they face risks including possible urinary incontinence and erectile dysfunction.
Lang also said the task force monitors research “all the time for important studies that will change our recommendations.”
“And if one of them comes along, we prioritize the updating of that particular guideline,” he said.
The Canadian Cancer Society pulled its endorsement from the task force’s website in December 2022, saying it hadn’t acted quickly enough to review and update its breast cancer screening guidelines to consider including women between 40 and 50.
“(The Canadian Cancer Society) believes there is an obligation to ensure guidelines are keeping pace with the changing environment and new research findings to ensure people in Canada are supported with preventative health care,” it said in an emailed statement Monday evening.
Some provinces have implemented more proactive early detection programs, including screening for breast cancer at younger ages, using human papillomavirus (HPV) testing to screen for cervical cancer and implementing CT scanning to screen for lung cancer, doctors with the Coalition for Responsible Healthcare Guidelines said.
But that leads to “piecemeal” screening systems and unequal access across the country, said Dr. Shushiela Appavoo, a radiologist with the University of Alberta.
Plus, many primary-care providers rely on the national task force guidelines in their discussions with patients, she said.
“The strongest association … with a woman actually going for her breast cancer screen is whether or not her doctor recommends it to her. So if her doctor is not recommending it to her, it doesn’t matter what the provincial guideline allows,” Appavoo said.
In addition to updating its guideline for breast cancer screening this spring, the task force is due to review its guidelines for cervical cancer screening in 2025 and for lung cancer and prostate cancer screening in 2026, according to its website.
This report by The Canadian Press was first published April 16, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
Nicole Ireland, The Canadian Press
Premature opioid-related deaths doubled in Canada after the onset of COVID-19 pandemic, and more than one in four deaths occurred in young adults, a new study suggested.
“The intersection of the COVID-19 pandemic with the drug toxicity crisis in Canada has created an urgent need to better understand the patterns of opioid-related deaths across the country to inform targeted public health responses,” the study authors wrote.
Some Canadian provinces were disproportionately affected by the crisis, they noted. For example, in Alberta, close to half of all deaths among people aged 20-39 years were opioid-related.
“Although the finding that the early loss of life was increasing over time was expected, the magnitude of this burden across Canada surprised me,” lead author Shaleesa Ledlie, MPH, a PhD candidate at the Leslie Dan Faculty of Pharmacy of the University of Toronto, Toronto, Ontario, Canada, told Medscape Medical News.
In addition to the increase in Alberta, she said, “in Manitoba, opioid-related death rates and the associated years of life lost increased almost fivefold between 2019 and 2021. This really reinforces the urgency of this issue across Canada and identifies regions where focused attention might be warranted.”
The study was published online on April 15 in Canadian Medical Association Journal.
Significant Increases
Researchers conducted a repeated cross-sectional analysis of accidental opioid-related deaths from 2019 through 2021 in nine Canadian provinces and territories. All provinces and territories for which age- and sex-stratified data were available at the time of the study were included: British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, New Brunswick, Nova Scotia, and the Northwest Territories. These areas represent 98% of Canada’s population.
Deaths were determined to be accidental or intentional by the coroner or medical examiner in each province or territory who investigated the death, according to Ledlie.
The primary outcome was the burden of premature opioid-related death, measured by potential years of life lost (YLL). The secondary outcome was the proportion of deaths attributable to opioids.
Overall, the annual YLL from opioid-related deaths doubled during the study period, from 3.5 YLL per 1000 population in 2019 to 7.0 YLL per 1000 in 2021.
In 2021, the highest burdens of death were observed among men (9.9 YLL per 1000) and young adults aged 20-29 years (12.8 YLL per 1000) and 30-39 years (16.5 YLL per 1000).
More than 70% of all opioid-related deaths occurred among men each year (73.9% in 2021), and about 25% of deaths occurred among people between the ages of 30 and 39 years (29.5% in 2021).
Geographic Variation
The annual increases by age and sex in each province and territory were generally consistent with the overall analysis. The observed changes in YLL over time varied geographically, however. They ranged from a 0.8-fold decrease in Nova Scotia (1581 YLL in 2019 to 1324 YLL in 2021) to a 4.7-fold increase in Manitoba (2434 YLL in 2019 to 11,543 YLL in 2021).
In 2021, the rate of YLL ranged from a low of 1.4 per 1000 in Nova Scotia to a high of 15.6 per 1000 in Alberta, whereas the absolute number of YLL ranged from 93 in the Northwest Territories to 111,633 in Ontario.
Between 2019 and 2021, the average percentage of all deaths attributed to opioids increased in all age groups. In 2019, 1.7% of deaths among people younger than 85 years were related to opioids. This proportion increased to 3.2% of deaths in 2021.
The largest relative increase between 2019 and 2021 (50.3%) was among young people. Opioid-attributable deaths increased from 19.3% to 29.0% among those aged 30-39 years. This change was followed by a 48.0% increase among those aged 20-29 years from 19.8% to 29.3%.
The authors noted that the study was limited by their inability to examine four provinces and territories for which the numbers of opioid-related deaths were suppressed because of small counts (ie, < 5). However, sensitivity analyses suggested that the demographic distribution of these deaths followed a pattern like that of the overall results.
More Information Needed
Commenting on the study for Medscape Medical News, S. Monty Ghosh, MD, MPH, an assistant professor at the University of Alberta, clinical assistant professor at the University of Calgary, and co-medical lead of Alberta Health Services’ Rapid Access Addiction Medicine program in Calgary, said, “The study was fairly robust in its evaluation. Their approach statistically is sound and makes sense, given the quality of data they received.” Ghosh did not participate in the analysis.
It would be important to know whether the premature deaths were polysubstance related, he noted. “More nuanced data in Alberta demonstrated that most of the deaths are related to polysubstance use on top of fentanyl. This includes alcohol, meth, as well as substance contaminants such as benzodiazepines, and more lately (outside of the research period), xylazine.”
Furthermore, Ghosh added, “It would be good to see more demographic information around the youth in Alberta. For instance, were they housed or unhoused? Are they Indigenous? Anecdotally, we know that blue-collar workers, especially those in Alberta who work in construction and oil rigs, have a disproportionate rate of substance use and at times substance death. This was seen in British Columbia and Ontario.”
What’s Being Done
The government of Alberta is responding to these data, said Ghosh. For example, in 2022, specialized funding was provided to enable young adults to access gold-standard opioid agonist treatment. The treatment was rolled out through Alberta’s Virtual Opioid Dependency Program (VODP) and other community-based addiction programs. “This [program] still needs to be more focused on homeless youth, however, who may not have access to technology or other resources.”
Furthermore, the government recently announced a $1.55-billion plan to continue building the Alberta Recovery model, he said. “This is the largest investment seen in our province. Safer supply or prescribed alternatives is very controversial in Alberta and thus is not an option available to this population.”
In addition, he said, the Ministry of Seniors and Community Social Services recently began “coordinated work with other ministries to support vulnerable and equity-deserving populations around this issue, including creating navigation centers for housing, income support, and access to treatment through the VODP.”
Ledlie noted that various policies and programs have been developed in response to the ongoing drug toxicity crisis. Some were included in a recent review that her team conducted to summarize the evidence from Canadian safer opioid supply programs. “We found that in general, these programs had positive impacts on clients, including reduced rates of opioid toxicities and improvements in quality of life.”
“Because most healthcare is coordinated at the provincial or territorial level, the investments into, and accessibility of, treatment and harm-reduction services tend to vary across Canada,” she said. “Even in regions where these programs exist, we know that they are not always accessible for various reasons, such as a lack of resources preventing widespread expansion and geographic barriers in more remote and rural regions.”
“One example of a simple yet life-saving harm reduction measure that has been effectively implemented by most provincial and territorial governments is the availability of publicly funded naloxone kits,” she added. “Given the widespread societal impacts of opioid toxicities described in our study, we believe it is pivotal for all levels of government to coordinate to ensure equitable access to evidence-based services across the country, while still providing the opportunity to tailor and adapt those responses to the unique needs of local communities.”
The study was supported by grants from the Ontario Ministry of Health and the Canadian Institutes of Health Research. Ledlie is supported by an Ontario Graduate Scholarship and the Network for Improving Health Systems Trainee Award. Ledlie and Ghosh declared no relevant financial relationships.
Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.
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