H5N1

Primary care for all: Lessons for Canada from peer countries with high primary care attachment

Via CMAJ: Primary care for all: lessons for Canada from peer countries with high primary care attachment. The key points:

• Canada spends less of its total health budget on primary care than the average among Organisation for Economic Cooperation and Development (OECD) countries (5.3% v. 8.1%).  

• Canada can learn lessons to inform policy on primary care from OECD countries like the United Kingdom, Norway, Netherlands and Finland where more than 95% of the population has a regular primary care clinician or place of care.  

• An analysis of these countries shows that those with high rates of primary care attachment have stronger contractual agreements and accountability for family physicians, including where they practise, their scope of practice and who they accept as patients.  

• Countries with high rates of primary care attachment have similar numbers of family physicians, but fewer work in walk-in clinics or specialized areas; family physicians are paid by capitation or salary, work in interprofessional teams and have excellent digital tools and information systems.

CIHI releases inaugural report exploring priority health care topics in Canada

A news release from the Canadian Institute for Health Information: CIHI releases inaugural report exploring priority health care topics in Canada. Excerpt:

August 2, 2023 —  The Canadian Institute for Health Information (CIHI) has released its inaugural report on priority health care topics, Taking the pulse: A snapshot of Canadian health care, 2023. This report is the first of what will be an annual series — the result of a formal commitment made in early 2023 by the Government of Canada and the provincial and territorial governments to improve health care in Canada in shared priority areas.   

As part of that commitment, governments agreed to work with CIHI to collect, share and learn from health information, with CIHI reporting to Canadians on the priority areas each year. Quebec is not participating in the joint reporting exercise.     

Taking the pulse: A snapshot of Canadian health care, 2023 offers Canadians an initial overview of where we are today in the 4 priority areas:  

• Expanding family health services and improving access to primary health care  

• Increasing the supply of health workers and decreasing backlogs in care to support resilient health systems  Improving access to mental health and substance use services   

• Modernizing health care’s information systems and digital tools for the secure sharing of electronic health information  

The indicator results (none of which include data from Quebec) are based on publicly available data stemming from a partnership between Canada Health Infoway, integrated youth services networks, Statistics Canada and CIHI.  

Selected indicator highlights include the following:  

• 88% of Canadians age 12 and older reported having a regular health care provider.  

• There were about 743,000 fewer surgeries performed in Canada during the first 2.5 years of the pandemic, a drop of about 13% compared with before the pandemic.  

• Half of Canadians who required community mental health counselling received a first appointment in less than a month, while 1 in 10 waited about 4 months (data is not available for Prince Edward Island, Quebec, Ontario and Nunavut).  

• Fewer than 40% of Canadians have accessed their personal health information online.

Outcomes and characteristics of patients hospitalized for COVID-19 in British Columbia, Ontario and Quebec during the Omicron wave

Thanks to FluTrackers for alerting me to this report in CMAJ Open: Outcomes and characteristics of patients hospitalized for COVID-19 in British Columbia, Ontario and Quebec during the Omicron wave. The abstract:

Background: Omicron is the current predominant variant of concern of SARS-CoV-2. We hypothesized that vaccination alters outcomes of patients hospitalized with COVID-19 during the Omicron wave and that these patients have different characteristics and outcomes than in previous waves. 

Methods: This is a substudy of the Host Response Mediators in Coronavirus (COVID-19) Infection (ARBs CORONA I) trial, which included adults admitted to hospital with acute COVID-19 up to July 2022 from 9 hospitals in British Columbia, Ontario and Quebec. We excluded emergency department visits without hospital admission, readmissions and admissions for another reason. Using adjusted regression analysis, we compared mortality and organ dysfunction between vaccinated (≥ 2 doses) and unvaccinated patients during the Omicron wave, as well as between all patients in the Omicron and first 3 waves of the COVID-19 pandemic.  

Results: During the Omicron wave, 28-day mortality was significantly lower in vaccinated (n = 19/237) than unvaccinated hospitalized patients (n = 12/127) (adjusted odds ratio [OR] 0.36, 95% confidence interval [CI] 0.15–0.89); vaccinated patients had lower risk of admission to the intensive care unit, invasive ventilation and acute respiratory distress syndrome and shorter hospital length of stay. Patients hospitalized during the Omicron wave had more comorbidities than in previous waves, and lower 28-day mortality than in waves 1 and 2 (adjusted OR 0.38, 95% CI 0.24–0.59; and 0.42, 95% CI 0.26–0.65) but not wave 3 (adjusted OR 0.81, 95% CI 0.43–1.51) and had less organ dysfunction than in the first 2 waves.  

Interpretation: Patients who were at least double vaccinated had lower mortality than unvaccinated patients hospitalized during the Omicron wave. Patients hospitalized during the Omicron wave had more chronic disease and lower mortality than in the first 2 waves, but not wave 3. Changes in vaccination, treatments and predominant SARS-CoV-2 variant may have decreased mortality in patients hospitalized during the Omicron wave.

How Canada’s decentralised covid-19 response affected public health data and decision making

This is a major report that deserves close attention. Via The BMJ: How Canada’s decentralised covid-19 response affected public health data and decision making. Excerpts:

Highs and lows of covid-19 response in Canada  

Highs 

• Public health leadership included women at each level of decision making. 

• Canada became one of the most vaccinated countries with >83% of the population receiving at least one vaccine dose in February 2023. After Health Canada approved Pfizer-BioNTech and the Moderna covid-19 vaccine in December 2020, rollout was prioritised for indigenous populations and those living and working in long term care homes  

• Research collaborations from basic science through to clinical and health services research emerged rapidly to address urgent questions of seroprevalence (eg, covid-19 Immunity Task Force), correlates of infection and immunity, and outbreak mitigation factors and engagement of patients in research conduct such as knowledge synthesis  

Lows  

• Failure to learn from previous reports led to failure to protect older adults and staff in long term care homes and among the highest proportions of deaths in this sector globally  

• Challenges to access and delivery of effective covid-19 medications such as tocilizumab, remdesivir, and ritonavir-nirmatrelvir resulted in provinces and hospitals rationing use  

• An exodus of exhausted and distressed healthcare workers, coupled with inadequate training paths for replacements, produced a critical workforce shortage that is ongoing  

• Canada lacked a coordinated system for evidence generation and use across government jurisdictions  

• Lack of research infrastructure embedded within the healthcare system limited Canada’s ability to participate in or lead clinical trials or other international studies 

• Lack of a clear and standardised approach to case definitions and testing contributed to inability to share use of data and make decisions           

• Absence of data sharing agreements across federal and provincial or territorial jurisdictions slowed or limited data sharing

Key messages

• Canada’s public health system was insufficiently prepared for the covid-19 pandemic

• Public health decisions and outcomes varied across jurisdictions and were hampered by outdated health information systems and lack of integration 

• Decentralisation of public health decision making has benefits such as tailoring interventions to local constituencies, but during a crisis, governance structures need to pivot to enable coordination and systematisation of data collection and analyses 

• Gaps in data and decision structures created a vacuum, filled by science advisory committees with disparate roles, responsibilities, and accountabilities within different jurisdictions 

• A shift to a culture of data access and shared analysis is needed to enhance health system learning and population health benefit, and for future crisis and pandemic preparedness

COVID-19 infections spreading fast in Japan’s Okinawa prefecture

Via The Japan News: COVID-19 Infections Spreading Fast in Japan’s Okinawa Pref.

COVID-19 is spreading rapidly in Okinawa Prefecture, with 48.39 cases reported per medical institution during the weeklong period of June 26-July 2, representing the highest figures across the nation. 

Hospital bed usage in the prefecture had risen to 78% as of Wednesday. “If the infection spreads nationwide, there’s a risk of the nation’s medical care system becoming strained,” said a member of an advisory body to the Health, Labor, and Welfare Ministry at a meeting on Friday.  

According to the Okinawa prefectural government, there were an estimated 12,260 cases in the prefecture, surpassing the 10,472 cases registered during the peak of the eighth wave of the coronavirus (from Jan. 2-8), when all cases were reported under a related law.  

As of Wednesday, the number of hospitalized patients, including those being treated at general wards, stood at 1,099 — nearly double the number 579 beds reserved to deal with the disease.  

At Okinawa Hokubu Hospital in Nago, the 25 beds secured for COVID-19 patients have remained almost fully occupied, forcing the hospital to use beds in a general ward.  

An increase in the number of medical staff unable to come to work due to personal or family-related infection has made it difficult for the hospital to maintain its normal system operations.  

“We’re asking inpatients to leave when their symptoms improve,” a doctor at the facility said. “The hospital is in the midst of the harshest ever situation.”  

On Thursday, the hospital announced a limit on nonemergency hospitalizations and surgeries until July 31.  

According to the prefectural medical association, an increasing number of medical institutions have been forced to restrict treatment or postpone surgeries.  

Previously, the prefectural government and public health centers would ascertain the status of infected individuals before assigning them to medical institutions. However, following the downgrading of COVID-19 to a Category V disease, patients have become concentrated at certain medical institutions due to lack of the coordination, severely stretching the prefecture’s medical care services.  

“The rise in the number of patients being hospitalized and an increase in cluster infections in hospitals have exacerbated the burden on medical services,” said a member of the ministry’s advisory body.  

The figure for confirmed cases reported by around 5,000 prefecture-designated medical institutions across the nation stood at 7.24 per institution, a 18% increase on the previous week.  

Takaji Wakita, chair of the advisory body and director general of the National Institute of Infectious Diseases said: “At the moment, infections are primarily spreading in western Japan. We need to keep an eye on whether this trend will spread nationwide.”

Health officials won't publicly admit scale of 'crisis' at Surrey Memorial Hospital ER, doctors' letter says

Via CBC News, yet more evidence of our health system's failure—and not just in one city or province, but nationwide: Health officials won't publicly admit scale of 'crisis' at Surrey Memorial Hospital ER, doctors' letter says. Excerpt:

Dozens of physicians working inside the busiest emergency room in British Columbia have released a scathing letter describing an unrelenting "crisis" at the department, claiming the local health authority has "repeatedly" asked them to keep details of the situation from the public.  

The medical professionals at Surrey Memorial Hospital said it's become necessary to speak out in violation of communications protocol because health-care leaders have not been transparent about the dire reality of overcrowding and inadequate staffing in the facility.  

More than 35 emergency physicians at the hospital backed the page-long letter that says patients are suffering and, in some cases, dying in hallways as a result of "steadily worsening" problems.  

"We have been repeatedly sounding the alarm to our regional and provincial leaders; these alarms have been ignored," read the letter dated Friday and obtained by CBC News.  

"Additionally, these conditions have been poorly and incompletely communicated to the public. We feel that patients and the public deserve honesty. Fraser Health has repeatedly told ER physicians to not openly discuss our 'challenges' with the public."  

CBC News is withholding the physicians' identities as they fear professional repercussions for releasing the letter.   

"It's scary, and we know we're going to get blowback on this. All we want to do is go to work and look after our patients in a reasonable way — and we feel like there's an incomplete truth that's been told," one physician said in an interview.  

"When a patient comes into the emergency department, and they see how busy it is, they see patients in hallways and corridors, there's a natural feeling that the emergency department is failing — and, truly, the emergency department is failing," they added.  

"But the failure is not because of your frontline emergency physicians, nurses, allied staff ... It's actually the system that's failing your emergency providers, and we don't have the resources to provide safe and appropriate care for all patients."

3 key issues, letter says  

The letter said three critical issues are contributing to the problem.  

First, a lack of acute care beds means patients who have already been admitted are taking up room usually reserved for incoming emergencies.  

"This bed-block forces us to routinely treat strokes, heart attacks, traumas, miscarriages and palliative patients in the hallway," the letter read.  

Second, the physicians said there are not enough hospitalists to admit patients from the emergency room to other wards, meaning patients linger in the emergency department for days. Doctors said some die while waiting.  

Third, the letter said elected leaders have failed to provide any "meaningful solutions" to the problem.   

The physician who spoke in an interview said the doctors decided to release the statement Monday after previous letters sent "all the way up the food chain," including to the B.C. Ministry of Health did not result in accountability or transparency.

China’s President Xi battles to save face as Covid U-turn weakens his grip on power

Via The Guardian: China’s President Xi battles to save face as Covid U-turn weakens his grip on power. Excerpt and then a comment:

China’s leader Xi Jinping told his country it stands on “the right side of history” in a new year address on Saturday, but experts have warned that the president starts 2023 diminished by his chaotic U-turn on Covid strategy.  

He may struggle to deflect blame for the human and economic costs of zero-Covid’s failure, and control the national narrative, even if public signs of dissent are crushed.  

Officially, China has registered just over 5,200 deaths from Covid, but there is a yawning gap between the picture presented by the usually efficient communist propaganda apparatus and the reality reflected in social media posts and anecdotes from across China.  

Hospital emergency wards are overflowing with desperate patients. Medical supplies are running low, with pharmacies selling out of drugs ranging from anti-viral to basic painkillers. Police patrolled one Beijing crematorium where Reuters reported long queues of hearses last week.  

In his first public comments to the Chinese people on Covid since his government changed course three weeks ago, Xi used his speech on Saturday to claim the government and Chinese Communist party (CCP) had “put the people first and put life first all along”.  

For many in China, that phrase will ring hollow, particularly those fighting for medical care for loved ones newly struck down by the disease.  

Questions about why the country clung so long to zero-Covid, at such heavy cost, and did so little to prepare for opening up are likely to undermine Xi, even if the damage to his authority isn’t visible beyond the walls of the secretive leadership compounds.  

“The fact that the CCP’s posture towards the pandemic has now completely reversed after a popular uprising can only mar Xi Jinping’s carefully cultivated air of infallibility,” said Orville Schell, director of the centre on US-China relations at the Asia Society in New York.  

“Xi is virtually immune from public expressions of criticism within China,” he added. “But my Chinese friends are all shaking their heads in incredulity at the contrariness of Xi’s policies.”

Foreign analysts, scouring the internet and official pronouncements for clues, estimate there are already thousands of deaths a day, with more to come.  

A first wave in urban areas is expected to peak in January, but a second, bigger wave will race through rural areas – where health systems are even weaker – in February and peak in early March, according to British health analytics firm Airfinity.

In a recent Tyee article, I argued that COVID-19 is only one of China's looming problems; economic uncertainty and climate disasters, especially water security, are making matters even worse.

Some hospitals in China overwhelmed in national COVID-19 wave

Via CBC News, an AP report: Some hospitals in China overwhelmed in national COVID-19 wave. Excerpt:

Yao Ruyan paced frantically outside the fever clinic of a county hospital in China's industrial Hebei province, 70 kilometres southwest of Beijing. Her mother-in-law had COVID-19 and needed urgent medical care, but all nearby hospitals were full.  

"They say there's no beds here," she barked into her phone.  

As China grapples with its first national COVID-19 wave, emergency wards in small cities and towns southwest of Beijing are overwhelmed. Emergency rooms are turning away ambulances, relatives of sick people are searching for open beds, and patients are slumped on benches in hospital corridors and lying on floors for a lack of beds.  

Yao's elderly mother-in-law had fallen ill a week ago with the coronavirus. They went first to a local hospital, where lung scans showed signs of pneumonia. But the hospital couldn't handle serious COVID-19 cases, Yao was told. She was told to go to larger hospitals in adjacent counties.  

As Yao and her husband drove from hospital to hospital, they found all the wards were full. Zhuozhou Hospital, an hour's drive from Yao's hometown, was the latest disappointment.  

Yao charged toward the check-in counter, past wheelchairs frantically moving elderly patients. Yet again, she was told the hospital was full, and that she would have to wait. 

'Terrified' over elderly woman's condition  

"I'm furious," Yao said, tearing up as she clutched the lung scans from the local hospital. "I don't have much hope. We've been out for a long time and I'm terrified because she's having difficulty breathing."  

Over two days, Associated Press journalists visited five hospitals and two crematoriums in towns and small cities in Baoding and Langfang prefectures, in central Hebei province. The area was the epicentre of one of China's first outbreaks after the state loosened COVID-19 controls in November and December. For weeks, the region went quiet, as people fell ill and stayed home.  

Many have now recovered. Today, markets are bustling, diners pack restaurants and cars are honking in snarling traffic, even as the virus is spreading in other parts of China. In recent days, headlines in state media said the area is "starting to resume normal life."  

But life in central Hebei's emergency wards and crematoriums is anything but normal. Even as the young go back to work and lines at fever clinics shrink, many of Hebei's elderly are falling into critical condition. As they overrun intensive care units and funeral homes, it could be a harbinger of what's to come for the rest of China.

Chinese doctors and nurses reportedly told to work while infected as Covid surges

Via The Guardian: Chinese doctors and nurses reportedly told to work while infected as Covid surges. Excerpt:

Chinese doctors and nurses are being told to keep working even when infected with Covid-19, staff and residents reported, as the virus rips through the population in the wake of eased restrictions.  

Some hospitals in Beijing have up to 80% of their staff infected, but many of them are still required to work due to staff shortages, a doctor in a large public hospital in Beijing told Reuters, adding he had spoken to his peers at other big hospitals in the capital.  

All operations and surgeries had been cancelled at his hospital unless the patient was “dying tomorrow”, he said, declining to be named due to the sensitivity of the subject.  

A senior World Health Organization official said on Wednesday that China’s flare-up started “long before” restrictions were lifted, but since the sudden shift in policy major cities in Beijing appear to have experienced a huge surge in cases of Covid-19. Authorities have said it is “impossible” to measure, since most people are not being tested.  

“The explosion of cases in China had started long before any easing of the zero-Covid policy,” WHO emergencies chief Michael Ryan said on Wednesday. “There’s a narrative that, in some way, China lifted the restrictions and all of a sudden, the disease is out of control,” he added at the UN health agency’s headquarters in Geneva.  

“The disease was spreading intensively because the control measures in themselves were not stopping the disease.”  

In Sichuan, a doctor surnamed Li told Reuters that their tertiary hospital was “overwhelmed with patients”.  

“There are 700, 800 people with fever coming every day,” Li said. “We are running out of medicine stocks for fever and cold. A few nurses at the fever clinic were tested positive, there aren’t any special protective measures for hospital staff and I believe many of us will soon get infected.”  

Claims of rampant infections among hospital staff are also spreading across social media. One Chongqing resident said primary care in their city had “imploded”.  

“80% of the newly admitted patients in our small third-level respiratory department in a remote city are positive,” they wrote on Weibo.  

“From December 8, when the first positive patient was allowed to be admitted, to today, December 13, at least half of the medical staff in our department were infected. At the beginning the infected were allowed to go home to rest, but now as long as it is not very serious symptoms, they are not allowed to go home.”

Keeping the front door open: Ensuring access to primary care for all in Canada

Via CMAJ: Keeping the front door open: ensuring access to primary care for all in Canada. The key points:

• Primary care in Canada is in crisis; 4.6 million people did not have a regular family physician or primary care clinician before the COVID-19 pandemic and the situation is getting worse.  

• Emerging evidence suggests that if primary care delivery does not change, a larger family physician workforce would be needed to serve the current population, let alone a growing and aging one. 

• Interprofessional team-based care, coupled with payment reform, has the potential to improve primary care capacity, access and outcomes for patients, and provider well-being.  

• Bold reforms could include neighbourhood-based clinics that employ physicians and have accountability to the local population and regionally organized after-hours care that would obviate the need for walk-in clinics and allow for better use of resources.