By now, we are all very much aware of the current pandemic, as we all try to remain at home as much as possible to stop the spread of the novel coronavirus and COVID-19 in the Kingston, Frontenac, Lennox and Addington (KFL&A) region.
What we don’t all know is what is actually being done by KFL&A Public Health in terms of case management, which includes tracking positive cases, following up with those who’ve possibly come in contact with a positive case (referred to as contact tracing), and following up with those who’ve tested positive until and after that case is considered resolved.
In an attempt to shed some light on how that process works, Kingstonist spoke with Dr. Azim Kasmani, a resident doctor with KFL&A Public Health. Here, we will break down how Public Health has and continues to monitor this situation locally.
Need to know facts
It is important to understand that coronavirus disease 2019, or COVID-19, is the illness caused by the novel coronavirus, which has been named Severe Acute Respiratory Syndrome coronavirus 2, or SARS-CoV-2.
Initial case management
According to Dr. Kasmani, the first thing that occurs when someone tests positive for COVID-19 is the beginning of the management of that case. This involves going over the case details submitted to KFL&A Public Health, either by a health care provider, or the COVID-19 Assessment Centre.
The KFL&A Public Health Team then does a thorough interview with the individual who tested positive, or their household contacts, depending on if the individual is able to be interviewed. These interviews serve to provide more information on the individual and the completion of a standardized form from the Ontario Government, which is based on the similar standardized form created by the Public Health Agency of Canada, Kasmani explained.
“So essentially, they are looking for more about the person, their risk factors and their medical history, how they’re feeling, etc.,” he said. “Also, they then look at potential exposures to see what has led to this person being diagnosed and then becoming ill.”
The interview then moves into looking into the individual’s close contacts – those who could have potentially come in contact with the individual who’s tested positive.
Once a list of close contacts has been established, the Public Health case and contact management team follows up with the contacts on that list. According to Kasmani, the team calls each individual on the close contact list regularly.
To determine who is a contact, the Public Health team look from two days before the individual who tested positive’s symptoms first started to appear, Kasmani said. The team also looks at the possible contacts the individual has had from those two days before symptoms appeared until 14 days after symptoms appeared. Close contacts are directed to self-isolate for 14 days, and are only released from isolation if they do not develop symptoms during that time.
“Contacts are contacted regularly, which is ideally daily, but depending on how well they are, it might be every other day, because we have to prioritize calling the people who are sick and checking in on them,” Kasmani said.
Those who have possibly been in contact with a positive case do not go for testing unless they have symptoms.
“Right now, the guidance from the Ministry is to test people with symptoms, and that’s because the best evidence we have right now is that the test is most accurate in people with symptoms,” Kasmani explained. “And if they have symptoms, then we have an indication that they might have the illness and should be tested.”
Those who have tested positive for COVID-19 and are self-isolating at home receive a call daily from KFL&A Public Health. During these calls, Public Health staff find out about the individuals current health status, and ensure that the individual is following the isolation guidelines.
Another part of case management is looking into how the individual may have contracted the virus.
“In finding out their exposure, we’re looking back the last 14 days at the probable exposure. That may be recent travel somewhere where there’s on-going community spread,” Kasmani said, “Or that may be close contact with an individual who has tested positive. So those would be the two areas that we would look at over the last 14 days for their exposure.”
In most cases locally, it is determined how the patient contracted the virus. According to Kasmani, the main scenarios of how the virus is contractedare: contact with someone who is ill, travel, or contact with someone who has travelled.
“If they don’t have any of that, then that would be evidence that they got it from somewhere that we don’t know. And that’s what you’re seeing a lot in the US right now where 97 per cent of people don’t have a known source of exposure,” Kasmani explained.
“One of the reasons is that their numbers are so large that they can’t do proper case and contact management. So we’re lucky here that our physical distancing measures have been put in place earlier to help slow the spread,” he continued. “And that’s really why we’re encouraging everybody in our community to follow the rules the province and the country has set out to help slow that spread so we don’t turn into a case like they are in the US or in Europe.”
Community spread is a term we hear often, especially when looking at the situations in the United States and countries like China and Italy where the novel coronavirus has had the biggest impact.
The definition of ‘community spread’ according to Merriam-Webster is “the spread of a contagious disease to individuals in a particular geographic location who have no known contact with other infected individuals or who have not recently traveled to an area where the disease has any documented cases.”
So do we have community spread in the KFL&A region?
“This is a really difficult question to answer because we are still able to make a link back to someone else who is unwell right now or has travelled, to get the source of that illness for most cases, except for a handful,” Kasmani said, noting that he is hesitant to say yes or no to the question of community spread locally because the situation is constantly changing.
Kasmani explained some of the difficulties this particular virus poses.
“One of the big challenges as well with this virus is that there is such a range of presentation. And so that makes it more challenging to know, because we may not be capturing everybody who has it, because not everybody may be becoming symptomatic to the level we’re expecting,” he said, noting that the virus affects people differently – some individuals who’ve contracted COVID-19 become very ill, others it doesn’t effect as much.
“And we have no idea why that is, or who to predict,” he said.
When is a case considered resolved?
Dr. Kasmani explained that, in determining whether or not a case is resolved, the Public Health team looks at a number of things, including the individual’s symptoms, how long those symptoms are lasting, and the experiences of people in Europe and China.
“What we see is that, for individuals at home, they are considered recovered 14 days after their symptom onset if their symptoms are better for at least 24 hours,” he said. “Although some people may have a slight lingering cough for a while, we know that, for any viral illness, you can have a cough for months after. So improvement or a resolution of symptoms for at least 24 hours, at least 14 days after symptom onset is considered resolved.”
For patients that are hospitalized, Kasmani said that ideally, those individuals are to get two negative polymerase chain reaction (PCR) test.
“Once they have two consecutive negative tests at least 24 hours apart, as well as symptom resolution, then they would be considered resolved,” he explained.
For patients that are not hospitalized and self-isolating at home, testing is not done to determine if the case is resolved.
“So if they’re well enough to be at home, and they then just need to be at least 14 days from their symptom onset, as well as resolution of their symptoms, then they would be considered resolved,” Kasmani said.
Once a case is considered resolved, the Public Health team continues to follow up with the individual for an additional 14 days for the development of symptoms.
“After 14 days if they are better, then they would be released from isolation. Otherwise, if they developed any symptoms, the clock would start again at 14 days from their symptom onset. They would then become cases and we would then manage their contacts,” Kasmani explained.
“The good thing is, they would already be in isolation and they would be practicing physical distancing, as we all are, so their contacts would be limited.”
Because the novel coronavirus and COVID-19 are completely new to the world and therefore the international medical community as a whole, there has been much speculation about various aspects of the virus and its treatment. One topic that continues to make headlines is that of COVID-19 cases relapsing after the case has initially been deemed resolved. Dr. Kasmani shared his thoughts on that.
“I personally don’t think it’s a common occurrence. One thing when we read some of those news articles is that the same patients will be referenced in multiple articles, and it seems like that’s very common,” he said. “There have been different theories that maybe they didn’t actually fully resolve, maybe they got a test that was negative or positive earlier that could have been a false negative or positive. But it seems unlikely. We can’t say it’s impossible in all cases, but I think that that would be the exception rather than the rule.”
The importance of this process
When asked how important the contact tracing and case tracking process is, Dr. Kasmani answered simply.
“It is vital,” he said.
As of Thursday, Apr. 16, 2020, KFL&A Public Health has received over 3,700 phone calls since the beginning of this pandemic. This includes up to as many as 250+ calls in a day.
“Our team members who are doing this are one of the most important parts. So areas that have been very successful in controlling their epidemics as part of the pandemic have used testing and then case management and contact tracing, and putting people who are close contacts into isolation, as well as the physical distancing guidelines and the various restrictions that have been put in place, that’s how they’ve done so well in reducing,” Kasmani expressed. “But case and contact management is very important. This is bread and butter public health work that we do for any sort of public outbreak that we have, and it’s no different here. Where we see that it’s most successful is where those strategies are used, and that’s why we’re implementing those strategies here, as well.”