Member Message — September 9, 2021
In this week’s message you will find:
- COVID-19 Situation Update
- Vaccine Update & Effectiveness
- Vaccine Requirements & Exemptions
- National Truth & Reconciliation Day
- Billing Audit?
- Doctors’ COVID tips for Back-to-School
- Fantastic Physicians
- Annual Bug Day — October 19
- The Pandemic Puzzles: Lessons from COVID-19
COVID Situation Update
Since our last update on Thursday September 2:
- Daily cases down: 307 new cases of COVID-19 have been identified since last Thursday, a daily average of 43 (down from 48 last week). This includes 54 new cases today. The total case count in Manitoba now stands at 59,100.
- Test positivity up: The provincial five-day test positivity rate is 2.6%, up slightly from 2.4%. It has decreased slightly in Winnipeg to 1.4%, from 1.5% last week.
- Active cases steady: There are 456 active COVID-19 cases province-wide, up from 430 last week.
- Variants of concern: 241, or 52%, of active cases are a variant of concern. Delta is the dominant variant of concern in Manitoba.
- Hospitalizations: There are 77 people in Manitoba hospitals due to COVID-19, up from 70. This includes 16 COVID-related patients in Manitoba ICUs, up from 15.
- Seven more people, including a male in his 80s reported today, have died from COVID-19. This brings the total COVID-19 related deaths to 1,199.
According to Health Canada’s tracking, Manitoba had 21 cases per 100,000 over the last seven days, down slightly from from 24 a week ago. Manitoba continues to have the lowest case rate outside of the Atlantic region. Alberta and Saskatchewan continue to lead the provinces with 217 cases per 100,000 in Saskatchewan (up from 156 last week) and 199 in Alberta (up from 171 last week).
When transmission reaches the substantial (50−99 cases/100K) or high levels (100+/100K), the CDC recommends indoor mask use. Alberta re-introduced a mask mandate in public places on September 4. Saskatchewan, however, has not yet brought back mask requirements, despite now having its highest new case rate so far during the entire pandemic.
The high level of transmission in Alberta is already causing a surge in hospitalizations and pressure on ICUs. Alberta Health Services announced today that all scheduled elective surgeries will be postponed in Calgary hospitals this week, where ICUs are overcapacity by about 29 patients today.
The Public Health Agency of Canada released its Update on COVID-19 in Canada: Epidemiology and Modelling last Friday. In the previous seven days Canada had seen an average of 3,486 cases, 1,230 in hospital, 443 in ICU and 13 deaths. Trends show hospital and ICU occupancy increasing, following weeks of rapidly increasing cases in some jurisdictions like B.C., Alberta and Saskatchewan.
Over 84% of the eligible Canadians (12+) have at least one vaccine dose and 77% are fully vaccinated. Vaccine coverage has increased as programs expanded to younger age groups, but uptake has slowed more recently, with the largest population protection gap being in the in 18 – 39 year old age group. More statistics show the efficacy of the vaccines. New cases among unvaccinated people were 12 times higher than in the fully vaccinated and hospitalized cases among unvaccinated people were 36 times higher than in the fully vaccinated.
The projection model shows that Alberta and Saskatchewan have a rapidly increasing number of cases. These provinces also have the lowest vaccination rates in Canada, combined with some of the least restrictive pandemic measures in place.
You can read the statement from the Chief Public Health Officer HERE and read the full report HERE.
COVID Hospitalizations are Expensive
The Canadian Institute for Health Information released a report today that shows an average COVID-19 hospitalization. Across Canada, the average COVID hospital stay cost $23,111, compared to $4,959 for an average stay due to influenza. In Manitoba, that average cost was about $1,500 higher, largely because the average length of stay was longer.
Vaccination Update and Vaccine Effectiveness
Since our last update on Thursday, September 2:
- 83.2% of Manitobans age 12 and up have received at least one dose, up only slightly from 82.3% a week ago.
- 78.1% have received two doses, up from 77.1% a week ago.
The province has started reporting some of its COVID-19 statistics by vaccination status on a new dashboard. New daily cases are broken down, along with active cases, hospitalizations and ICU patients.
For the 456 active cases in Manitoba today, the dashboard reveals that 58% are not vaccinated, 11% are partially vaccinated, and 31% are fully vaccinated. Among hospitalized COVID-19 patients, only 11% are fully vaccinated, and among ICU patients 0% are fully vaccinated. For today’s 54 new case, only 35% were fully vaccinated.
Doctors Manitoba applauds making this information available, though we are concerned it could be interpreted incorrectly by Manitobans who may not consider the unequal size of the fully vaccinated vs. unvaccinated populations in our province. Those who are hesitant or skeptical about the COVID-19 vaccines could conclude that the vaccine isn’t working if 31% of active cases are fully vaccinated. But, “31% of new infections were fully vaccinated” is VERY different than “31% of vaccinated people got infected.” This phenomenon is a cognitive error called the “base rate fallacy” where individuals tend to give more weight to numbers than we should, because we aren’t aware of, or ignore, the base rate.
It is important to put this information into context, as a recent Planet Money podcast did in looking at the base rate fallacy of how breakthrough COVID-19 infections are often misinterpreted. Comparing the number of cases by vaccination status in a highly vaccinated population provides a misleading view of vaccine ineffectiveness. The rate of cases among these populations, however, help to paint a more accurate picture. A recent article intended for journalists helps to explain this issue further, noting that “the more vaccinated a population, the more we’ll hear of the vaccinated getting infected.”
Here are some things to consider when discussing this with patients concerned about vaccine effectiveness:
- When you hear that some new COVID cases were among fully-vaccinated individuals, you have to consider that the large majority of Manitobans are fully vaccinated but they only account for small minority of the new cases.
- While the COVID-19 vaccines work very well, no vaccine is 100% effective at preventing infection.
- Real-world evidence is showing us that COVID-19 vaccines decrease the risk of infection, and more importantly they work very well at decreasing the risk of severe illness and death.
Data for the last few weeks in Manitoba suggest that the rate of new cases per week are about 8.6 per 100,000 fully vaccinated individuals compared to 54.5 per 100,000 unvaccinated individuals.
Perhaps the best way to put this for patients comes from the report on new PHAC COVID modeling:
- New cases of COVID-19 are 12 times higher among unvaccinated people than fully vaccinated people
- COVID-related hospitalizations were 36 times higher among unvaccinated people than fully vaccinated people.
Vaccination Requirements & Exemptions
We continue to receive questions from members about vaccination requirements, including how to respond to patient requests for exemptions, how to implement the requirement in your practice, and whether such a requirement is legal. Below, you will find answers to many of these questions based on what we know today. We are still waiting for final details from the province, so these answers may change as we learn more.
Where will vaccination be required?The requirement to be fully vaccinated is being implemented in Manitoba in two broad ways:
- To access several public places, such as restaurants, gyms, major events among others. Proof of full vaccination is required to access these designated places. This is now in effect — read more here.
- To work in health care and other parts of the public sector, individuals must be fully vaccinated or receive negative COVID-19 tests up to three times per week. This is not yet in effect, as employees have until October 17 to get their second dose, so they are considered fully vaccinated by October 31. Read more here.
What will this mean for my practice?
We recommend all physician practices adopt the provincial vaccination and testing requirement. All physicians, regardless of practice location, will be required to be fully vaccinated. However, we do not yet know how the rules will apply to staff working in a physician-owned medical clinic. These details should be available very soon. For now, review our advice from last month here, and prepare to implement this policy in your practice.
How do I handle requests for medical exemptions?
Physicians may face requests for a vaccine exemption for medical reasons, both from patients and their employees. We understand provincial direction will be available soon on this, including a referral pathway. We anticipate that a referral to a relevant specialist will be required to assess and verify a relevant medical reason exists to grant an exemption, and we expect this will include a very specific and limited list of medical conditions.
For mask exemption requests, we believe the same advice from earlier in the pandemic still applies. You can find guidance on that here.
How do I handle patients with allergies?
Allergies to a COVID-19 vaccine or vaccine components are quite rare. Where a legitimate allergy exists, it may not be a contraindication to receiving the vaccine. In fact, the HSC Allergy and Clinical Immunology clinics have been using protocols for testing and administration of COVID-19 vaccine to patients with suspected or confirmed allergy to the vaccine. These protocols have allowed numerous patients to be vaccinated who otherwise would not have received protection.
The following advice from the Allergy and Clinical Immunology group will help physicians screen and refer potential allergies for review:
- Allergies to medication (not including PEG), food, venoms, or environmental allergens are not a contraindication to receive the COVID-19 vaccine and should not be given exemptions
- Allergy to previous non-COVID-19 vaccines (without shared ingredients to COVID-19 vaccine) is not a contraindication to COVID-19 vaccine
- Patients with suspected or confirmed allergy to a COVID-19 vaccine or vaccine component should be referred to the HSC Allergy and Immunology clinic for further evaluation and specialized administration of the vaccine
- Exemptions for allergy reasons are only to be given by an Allergist/Immunologist when deemed appropriate. Exemptions for non-allergic reasons are not able to be given by Allergists. For adverse reactions unrelated to allergy, such as neurological or cardiac symptoms, patients should be referred to the relevant specialty.
- For more information please see the Canadian Society of Clinical Immunology and Allergy COVID-19 Vaccine Allergy FAQ
Referrals for suspected allergy to COVID-19 vaccine or component:
- HSC ADULT Allergy and Clinical Immunology Clinic Fax 204−940−2223
- HSC PEDIATRIC Allergy and Clinical Immunology Clinic Fax 204−787−5040
- Allergy Physicians are also available on call through HSC paging (both pediatric and adult). As well, eConsult service is available for any questions.
Links to the full list of vaccine ingredients can be found on this page at ManitobaVaccine.ca.
What about other requests for vaccine exemptions?
Doctors Manitoba has issued public positions supporting the expanded use of immunization cards in public places and recommending a requirement for vaccination in health care and other sectors. Both of these positions followed consultation with members, and were carefully drafted to respond to concerns from a small number of members about the impact on personal human rights.
The Manitoba Human Rights Commission has just released guidelines about human rights and vaccination requirements.
The Commission explains that vaccines play a critical role in “protecting the health and well-being of our communities” and makes it clear that “increased vaccination rates safeguard human rights by protecting individuals most at risk of severe COVID-19 related outcomes.” They also recognize that vaccination “reduce[s] the need for restrictive public health measures.”
Ultimately, the Commission notes that a “careful balance” is needed between individual rights under the Human Rights Code and individual and collective rights to health and safety.
Highlights of the guidelines include:
- Recognizing that some Manitobans cannot be vaccinated for reasons protected under the Human Rights Code, such as disability or age.
- Personal choice not to be vaccinated is not considered grounds for a human rights complaint against an organization’s mandatory vaccination policy, “especially where that choice is based on misinformation or misunderstandings of scientific information.”
The human rights of everyone involved should be considered when developing a vaccination mandate. The Commission advises all employers, including physicians that “every measure must be taken to eliminate barriers to access for people who would like to receive a vaccination against COVID-19.” Manitoba physicians are in a strong position to provide employees with current information about, and convenient access to, a COVID vaccine.
You can read the entire Human Rights Commission guidelines here. You can also watch a recent webinar we held last month about this issue, with an expert medical and legal panel.
National Day for Truth and Reconciliation (Sept 30)
The federal government has designated September 30 as the National Day for Truth and Reconciliation. The federal statutory holiday is intended to give the public a chance to recognize and commemorate the intergenerational harm that residential schools have caused to Indigenous families and communities, to honour those who have been affected by this injustice and to inform further action in the spirit of reconciliation.
The province of Manitoba has not yet recognized this as an official provincial statutory holiday, but it has indicated that the day will be recognized this year as a “day of observance.” Schools will be closed on September 30 and most provincial offices and non-essential public services will be closed.
How does this impact the health care sector?
Shared Health has indicated that maintaining access to health services will be a priority on September 30 this year, because of the backlog of medical care following pandemic disruptions. Physicians working in hospitals or other RHA-run facilities should expect to see normal weekday hours of operation unless otherwise notified by the health facility or RHA.
While not an official provincial statutory holiday, September 30 will be treated as such under collective agreements, alternately funded agreements and for the purposes of the Physician’s Manual for this year. For physicians, this means your remuneration will be treated as it would on an existing provincial statutory holiday, such as Louis Riel Day or Victoria Day.
What should physician clinics do?
If you own or run a medical clinic, you can decide how to observe this day this year. We encourage physicians to consider the following:
- Remain open? While schools, government offices and some private employers are deciding to close, medical clinics can make a decision about remaining open or closed on the National Day for Truth and Reconciliation. Because this is not a provincial statutory holiday, there is no requirement to close. We anticipate most clinics will remain open this day, consistent with the rest of the health care system.
- Employee right to statutory pay or day off in lieu? Because this is not a provincial statutory holiday, private employers are not required to provide employers statutory pay or a day off in lieu if you remain open. However, the public sector has announced it will treat this day as a statutory holiday, which means public sector employees will either have the day off or receive statutory holiday pay. Physicians who are also employers may wish to consider this when developing their plan for the day. Further, it is important to review any collective agreements or employment contracts, as sometimes these indicate employees will be entitled to any provincial or federal statutory holiday.
- Reinforce the purpose of the day with your staff. Many employers are sending their staff a list of educational resources to help honour the purpose of the day. Doctors Manitoba will be developing a list of resources, and we can share this with physicians who are also employers.
Billing Audit? Call Doctors Manitoba First.
We are seeing an increase in government audits of physician billing, and so far we are seeing a more assertive approach. If you receive an audit letter, please call Doctors Manitoba first to get advice and guidance on navigating this process.
Our negotiations and practice advice team is helping members through the audit process, and we’re finding auditors are trying new and more approaches. This follows an Auditor General investigation into physician billing audits earlier this year, and the government’s response to add more audit staff and move the auditing function to the Department of Finance’s Comptrollership and Compliance Unit. Our team has noticed that auditors are more rigorous in reviewing physician documentation in patient charts, and at times have questioned clinical decisions.
We had anticipated the government would step up its audit capacity, which is why we are expanding our capacity to support more members through the process. Physicians are reminded that accurate and complete documentation is crucial for many reasons, including for a potential future audit of your billing claims.
Call us first if you receive an audit notice. You can also review our Physician Remuneration Audit Guide, and our advice about being cautious when speaking directly with auditors.
Please contact Allison Crolly at email@example.com or (204) 985‑5856, or Andrew Swan at firstname.lastname@example.org or (204) 985‑5860 if you receive an audit letter.
Back-to-School COVID Tips
This week Manitoba children returned to school. Parents and caregivers may have questions and concerns about a return to in-person learning as we approach the forecasted fourth wave. We’ve partnered with Shared Health to create a list of Doctors’ COVID Tips for Back-to-School.
What can parents do?
- Keep kids home if they have symptoms. Follow public health guidance about screening, testing and isolation.
- Make masks comfortable. Ensure your children have comfortable masks they like, and practice putting them on and taking them off.
- Reinforce the basics. Frequent hand hygiene, physical distancing when possible, safe snacks and lunches.
- Support children’s mental well-being. Stay positive. Avoid social isolation. Focus on what you can control. Limit the amount of COVID news during family time.
- Get vaccinated. Everyone in your household should get vaccinated if they are eligible. This also helps protect kids under age 12.
What should schools do?
- Reinforce the basics, including frequent hand hygiene, symptom screening, proper mask wearing.
- Support vaccination for teachers, staff and eligible students.
- Follow ventilation guidelines for an added layer of protection
- Promote physical distancing whenever possible, and avoid congestion in common areas.
- Be ready to change precautions, as the level of transmission changes in the community.
You can suggest patients watch our on-demand Back-to-School Town Hall or use the Doctors’ COVID Tips for Back-to-School social media graphics we’ve created to give comprehensive and concise answers about safety and COVID-19 in schools.
Jayelle Friesen-Enns, a Métis, third year medical student, received a Canadian Medical Hall of Fame (CMHF) award. The award is given to medical students who demonstrate community leadership, superior communication skills and an interest in advancing knowledge. Jayelle, who is concurrently completing a master’s in medical microbiology and infectious diseases, co-founded the Indigenous Medical Students’ Association of Canada (IMSAC) to provide a space for advocacy and support for Indigenous medical students who often face additional barriers to achieving their educational goals. Read more about Jayelle HERE.
Bug Day 25th Anniversary!
On October 19, 2021, the Health Sciences Centre is hosting Bug Day 2021 in conjunction with the Department of Continuing Professional Development (CPD) at the University of Manitoba.
This is the 25th year for this popular event! This year, the program is:
- Completely free!
- Completely accredited for primary care and specialist physicians!
- Completely virtual!
To receive credit for attending Bug Day 2021, you must register through the University of Manitoba.
For Bug Day 2021 presentations will address a broad range of topics in Infectious Diseases, Public Health and Infection Prevention and Control. The program will be fast-paced, with multiple opportunities for audience engagement. For more information about Bug Day, please visit the event site here.
The Pandemic Puzzle: Lessons from COVID-19
Stanford is offering a free, virtual 4‑part series that will convene experts and leaders from business, government, biomedicine, and public health who have been at the helm of the COVID-19 response. Together, we will explore what has worked, what hasn’t, and opportunities to strengthen our resilience and preparedness for current and future threats. Each half-day session will focus on a unique theme:
- Session #1 | Friday, September 17: Responding to a Global Pandemic
- Session #2 | Wednesday, October 13: Building Towards Health Equity and an Inclusive Recovery
- Session #3 | Thursday, October 28: Tracking and Mitigating a 21st Century Pandemic
- Session #4 | Friday, November 19: Agile Discovery and Innovation: Advancing Tomorrow’s Vaccines, Treatments, and Cures
The sessions are free but you must register. Find out more HERE.