Maintaining Regular Primary Care Practice in the COVID-19 Context

Last Updated: July 6, 2020

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The Maintaining Regular Primary Care Practice in the COVID-19 Context resource is revised often and new content is added regularly to guarantee that the latest evidence and regulatory recommendations are included. The CEP is committed to ensuring this information is accurate and up to date.

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Your one-stop shop for all of your COVID-19 related needs, including clinical guidance, maintaining regular primary care practice in the COVID-19 context, Ontario assessment centres, social care guidance, local services and more.

Now more than ever it is important for your patients to look after their health and receive care from you as their healthcare provider. It’s essential that patients continue to seek out care that they need.

Navigate through patient care in a world where COVID-19 is the “new normal.” Use this resource to provide day-to-day care in a familiar but different environment. From child mental health to opioid use disorder and other conditions, this interactive resource covers topics providers see with their patients every day while considering present-day obstacles due to COVID-19.

Check back daily for the latest updates.

Click on the sections below to get started:
Adult mental health
Last reviewed: July 6, 2020
Last updated: July 6, 2020
Urgent care

Remind patients that if they are experiencing a mental health crisis, they should call 911 or report to their local emergency department (CAMH, April 6, 2020). For a list of crisis lines in Ontario, visit eMentalHealth.ca .

Consult COVID-19 and the Mental Health Act (CAMH, 2020) for information on the completion of Form 1s, and guidance on the completion of Form 1, 3, 4, 4A, 49 and capacity assessments via phone or video.

Strategies to maintain wellness

Discuss the following strategies with patients to help them maintain wellness throughout the pandemic (CAMH, April 6, 2020).

Accept that some anxiety and fear is normal: Reassure your patients that some stress and anxiousness surrounding the COVID-19 pandemic is normal and can help motivate them to protect themselves. Consider directing patients to the Coping with stress and anxiety during the COVID-19 pandemic worksheet (CAMH, March 2020), to help them to challenge their own anxious thoughts and worries, especially those seemingly based on fear and not facts.

Seek credible information: It is important to emphasize to your patients that although staying informed can help us to limit the spread of the virus, misinformation and excess information can cause stress and anxiety. Encourage your patients to stay tuned in to credible sources (such as Ontario Ministry of Health, Health Canada, World Health Organization), but to find a balance in terms of how often they seek information – especially as daily changes are not likely to affect how they should manage their individual risk.

Seek support: Remind your patients that physical distancing does not mean that they cannot contact their loved ones. Encourage them to:

  • Reach out and get support through phone calls, video calls or text messaging.
  • Look for formal supports, either online or by phone. For example, distress lines, online support groups, or resources in the community. See Top resources for more information on formal supports.

Practice a healthy lifestyle: Emphasize to patients that while physical distancing, it is still crucial to practice healthy habits.

Identifying and supporting patients
Supporting patients with pre-existing mental health conditions

If the patient has already been diagnosed with a mental health condition such as depression and/or anxiety, their symptoms might be worsened by feelings arising from the pandemic. It is important to provide them with resources to cope, while adjusting treatment as required.

Opportunities to reach out to patients with pre-existing mental health conditions:

For patients with scheduled appointments (even those that are non-mental health related), consider using it as an opportunity to inquire about the patient’s mental health and how they are coping with the current situation.

When feasible, consider proactively identifying patients who have been diagnosed with a mental health condition and reach out to book a remote/virtual appointment.

Managing pre-existing mental health conditions
Scenarios to consider for patients with pre-existing mental health conditions:
  1. Patient in active treatment and in an active phase of symptoms prior the pandemic (March 11, 2020).
  2. Patient was on maintenance treatment, but is now in partial remission.
  3. Patient had been in full remission and stable, and is now undergoing relapse.

In addition to existing pharmacotherapy and psychotherapy treatment, leverage existing tools and use the following guidance to manage patients with mental health conditions:

Ensure patient has access to resources. Provide virtual resources for supports (see Top resources below).

Ensure patient has access to their medications: Let patients know they can refill their prescriptions online and use pharmacy delivery or curbside pickup to minimize contact. For a list of local pharmacies to arrange delivery or pick-up, see Local services > Pharmacies.

Provide patients with coping strategies to maintain wellness. See Coping with stress and anxiety (CAMH, April 6, 2020).

Increase monitoring of these patients by repeating assessment scales (e.g. PHQ-9, GAD-7) at regular intervals.

For patients undergoing a relapse, determine if presentation is consistent with prior diagnosis and treat accordingly. If the patient is presenting with different symptoms, conduct a formal assessment using:

For local community services and resources that you can connect your patients to, see the CEP’s Local Services Resource for:
Supporting patients with new cases of mental health conditions
New cases can include:
  1. Conditions now surfacing because of circumstances involving isolation, stress, and fear, but which were previously mitigated by activities and supports.
  2. Mental health conditions due to the patient’s response to an absence of regular routines, in addition to pandemic-induced stress.
Managing new cases of mental health conditions

Use remote/virtual care to document and monitor patients with new mental health diagnoses. See the Primary Care Operations in the COVID-19 Context resource for details on delivering patient care remotely and in person.

Frequency of monitoring should be determined and/or adjusted when clinical decisions are being made or at scheduled follow-up appointments (e.g., if starting medication or when doses are being adjusted).

With respect to initiating treatment that may require regular blood work, such as lithium and valproic acid (CANMAT, 2020), take into consideration the patient’s ability to attend laboratory appointments during the pandemic.

For local community services and resources that you can connect your patients to, see the CEP’s Local Services Resource for:
Top resources

Patient resources

Cognitive behavioural therapy (virtual resources apps)

Addiction and problem gambling treatment services

These supporting materials and resources are hosted by external organizations. The accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

Alcohol use disorder (AUD)
Last reviewed: July 6, 2020
Last updated: June 25, 2020

The Alcohol Use Disorder (AUD) in the COVID-19 Context tool has been developed to support primary care providers in navigating and providing patient care in a world where COVID-19 is the ‘new normal’, with considerations and recommendations on what’s ‘new’ and what’s ‘changed’ in the delivery of care for patients living with AUD.  While how care is delivered has changed, efforts should be made to ensure that the quality has not. As always, when treating your patients, continue to use your clinical judgement and follow standards of care, best practices, evidence and guidelines.

Child mental health
Last reviewed: July 6, 2020
Last updated: July 6, 2020
Talking to children about COVID-19

Parents and caregivers should ensure children receive honest and accurate information during the COVID-19 pandemic (SickKids, March 31, 2020).

Talking tips:

  • Share ‘need to know’ information with children, using age appropriate language.
  • Answer questions directly and honestly, and do not make false promises.
  • It’s okay if you don’t know all the answers. Focus on the short-term plan for the whole family.
  • If children are distressed, let them know that it is ok and understandable to have these feelings.
  • Model healthy coping skills and attend to your own physical and mental health.
  • Consider seeking out additional resources and supports for children with special needs or who are having trouble coping. For a list of local mental health services for families, children and youth, see Local Services > Mental health services.
Answering children’s questions about COVID-19

“We wipe things down to keep them clean.”

You don’t need to explain more than this—young children don’t understand germs or infection transmission yet.

“Sometimes people wear masks to decrease sickness from spreading, when they aren’t feeling well or to help keep them safe from getting sick.”

“Everybody gets sick sometimes. If you get sick, your parents will take care of you until you are all better. I will help you, too.”

“Your child care/school is closed right now. Your teacher and your friends are home too, just like you. When child care is open again, you can go back and see your friends.”

Avoid going into details about illness so toddlers don’t develop fears about attending child care.

“Right now, there is a rule that families need to stay home for a little while and be together. That helps you and your friends stay healthy. I know it can be sad when you can’t see and play with friends, but there are lots of fun things you can do at home!”

Preparing children for reopening

Reopening is presenting kids with a different set of anxieties and challenges. Doing the following, parents and caregivers can help children adapt and prepare for the changes resulting from COVID-19:

Plan, but stress flexibility

Even if only a few weeks at a time, planning ahead will help give kids a sense of safety and security. Children should be included in planning and informed that these plans might have to be reassessed. This can lessen their anxiety over how they’ll be spending the next few months and help them prepare to handle changes.

Agree on ground rules

Establishing clear family rules for socializing will give kids a sense of control. Empathize with their fears, but encourage them to think of ways that your family will work together to help everyone stay safe and healthy.

Take it step-by-step

Emphasizing that reopening is a gradual process can help kids manage their behaviour and feel more confidence. Steps to start with might include maintaining physical distancing or wearing a mask while with friends, or limiting the number of friends your child can see. Discuss what other steps might come down the road so kids know you’re planning ahead even if they can’t do everything they want just yet.

Prepare children by coping ahead

Other families might follow different rules, which could result in uncomfortable moments for kids. Work with kids to anticipate unsafe situations they might encounter so they feel more comfortable and can make better decisions when the time comes.

Validate fears

When a child expresses worry or fear, helping them know their feelings are valid will help manage those feelings. Instead of telling them not to worry, try to find out what they are worried about and answer their questions to correct any misinformation.

Practice bravery

Encourage kids to do various activities in their neighbourhood, such as go on a bike ride or play games outside, and ask them which one they think would be the easiest. Pair this with praise or even a reward for trying one of these activities.

Be alert to signs of something more serious

Look out for signs of mental health distress as discussed in following sections.

Recognizing the signs of mental health distress

Changes in behaviour or emotions can indicate that a child needs more support (CPS, March 2020; SickKids, April 14, 2020; School Mental Health Ontario, 2020; Child Mind Institute, 2020).

Look out for:

  • Changes in behaviour or emotions that seem out of proportion even with the current circumstances (e.g. angry outbursts, depressed mood, sense of panic).
  • Problems sleeping; shifts in sleep patterns.
  • Appetite changes; changes in weight.
  • Headaches, stomach aches/nausea and fatigue.
  • Infantile behaviours that aren’t common anymore for the child (bedwetting, thumb sucking, being afraid of the dark, wanting to be held).
  • Loss of interest in activities they enjoy; reduced feelings of anticipation.
  • Worry and/or fear of leaving the home.
  • Increased rebellion and/or complaining about schoolwork or chores.
  • Increased aggression towards others.
  • More frequent outward expression of emotions.
  • Harsh self-assessment.

If a child expresses thoughts of hurting themself or engages in suicidal behaviour, seek help from a mental health professional immediately. For a list of local mental health services for families, children and youth, see Local Services > Mental health services.

Managing depression
Managing stress and anxiety

Use the CARD System (Comfort, Ask, Relax, Distract) to help children cope:

  • Comfort: help the child accept negative thoughts and feelings.
  • Ask: listen and talk to each other.
  • Relax: model relaxation for the child.
  • Distract: try to keep normal routines and limit the amount of time the child focuses on whatever is making them anxious.

General actions to help support children during the pandemic (WHO, 2020):

  • Support children with at-home learning, and make sure time is set aside for play.
  • Help children find positive ways to express feelings such as fear and sadness. Sometimes engaging in a creative activity, such as playing or drawing, can help with this process.
  • Make sure children have time away from screens every day and spend time doing off-line activities together. Draw a picture, write a poem, build something, bake a cake, sing, dance, or play outside where safe to do so.

Actions to combat disconnectedness:

When a family member is self-isolating
Grief

Children experiencing the death of someone close to them are particularly vulnerable (Canadian Virtual Hospice, 2019). They need time to process their thoughts and feelings and to ask questions. Willingness to discuss difficult topics teaches children that hard conversations can happen safely, and that they can talk with you about difficult things (Canadian Virtual Hospice, 2019).

Talking to a child about the loss of a loved one:

  • Have the conversation in a safe, comfortable place where you won’t be interrupted.
  • Get down to eye level.
  • Tell them that you may be upset or cry while you talk because you’re feeling many emotions, and that this is natural and okay.
  • Explain that they may have strong feelings too and it’s okay to express them.
  • Start with what the child already knows and build from there.
  • Give the information in a straightforward way, using words they can understand.
  • Let them know their questions are welcome. Praise them for asking questions and sharing their thoughts and feelings.
  • Be gentle and sensitive, giving the information they ask for and need.
  • Watch for cues to guide you around pacing the conversation, signs that will help you gauge how much information to provide and when the child is ready to hear it.

Top resources

These supporting materials and resources are hosted by external organizations. The accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

Chronic non-cancer pain (CNCP)
Last reviewed: July 6, 2020
Last updated: June 22, 2020
Patients living with Chronic Non-Cancer Pain (CNCP) may be at an increased risk for:

Contracting COVID‐19. CNCP may cause immunosuppression in some individuals, while opioids and steroids used by patients experiencing chronic pain can also suppress the immune response, increasing the risk of infection.

Experiencing mental health concerns. Social isolation, stigma, loss of personal identity and financial stress, exacerbated during a pandemic, can negatively impact a patient’s quality of life and ongoing experience of pain.

Managing patients living with CNCP

Ensure continuity of care for those living with chronic pain during the COVID-19 pandemic.

Where feasible, minimize in-person visits to reduce their exposure risk.

  • For all non-urgent patient appointments, use remote/virtual care for pain assessment and management, whenever possible.
  • For semi-urgent patient appointments, use remote/virtual care approaches to evaluate the patient, triage the urgency and make suitable arrangements for further treatment and/or assessment that can include in-person care.

See the Primary Care Operations in the COVID-19 Context resource for details.

Emphasize biopsychosocial focus and multimodal management. Leverage remote/virtual platforms to support patients to engage with their multidisciplinary pain management team (physical therapist, psychologist, social worker, etc.).

Encourage and help connect patients with online supports:

Educate patients about their treatments and modify ongoing therapies to decrease COVID‐19 risk.

Remote/virtual care for CNCP

Technology options: When deciding on the best format to provide remote care, consider audio and video quality, background distractions, and lighting. If possible, maintain contact with patients on a regular basis (e.g. once a week or once a month) and avoid switching to PRN contact only. See Primary Care Operations in the COVID-19 Context > Delivering patient care remotely for more information on providing remote care.

Troubleshoot technical issues: If technical issues occur during a session, use this opportunity to model and practice effective problem-solving skills with the patient. Have a backup option agreed upon with the patient in advance.

Scheduling appointments: Ask patients to schedule appointments at a time and place that is free of distractions, so that they will be able to focus on your discussion. In the case of child or adolescent patients, help to structure the session to allow time with both the child and parent. Whenever multiple people are in the room, ask for introductions of all present.

Complementary resources: Identify remote self-help interventions that the patient may use in combination with remote sessions with their healthcare provider. These may include online self‐management programs, books, online materials, smartphone apps, etc.

Positively reinforce patient’s self-management efforts: One of the best ways to do this is to ask for details about strategy use (e.g. what strategies seem to work, where and when did you use the strategy, and what was the outcome). Ask patients about how they motivated themselves to use that strategy and how things went different when they used it. If patients are using self-help online intervention, ask patients specifically what part of the online program or app they have reached and how they have been using the strategies.

Problem solve: Work with the patient to problem solve around difficulties in managing pain. Use a patient-centered approach that encourages them to identify barriers and implement potential solutions. The current context of COVID-19 brings specific challenges to problem solving, and potential anxiety behaviour should be accounted for.

Experiential learning: If possible, include some experiential learning in the session, i.e. work with the patient on a task that may help them in managing pain. This might take the form of helping them develop a daily schedule for their pain management efforts (i.e. taking medication, doing physical exercises, and engaging in physical activities that are meaningful to them). Or it might involve guiding the patient through a brief imagery, meditation, or relaxation exercise. Try to enhance patient mastery of the task by asking the patient what about the task or exercise was easier for them (and why) and what challenges they experienced and how they might address them.

Setting goals: At the end of the session, work with the patient to identify specific goals that are meaningful to them and doable that they should complete before your next session. Let them know you will start the next session by going over the goals with them.

Self-help activities: Integrate self-help activities into the overall treatment goals. At the end of the session, assign patients a specific self-help task to complete before their next session (e.g. download app, work through the first exercise).

Remember the context: Always be flexible: this is a stressful time for everyone, but particularly for those with long-term conditions. Each patient will be dealing with extra pressures (e.g. financial, childcare, and health of others) that may influence their pain and ability to cope.

Management of patients by medication
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  • Opioids
    • An in-person evaluation may not be needed for continued management.
    • An in-person evaluation is required for any significant, sustained increase in opioid prescribing.
    • Ensure patients receive their appropriate prescriptions to avoid withdrawal. Ensure availability of naloxone kits and training on their use.
    • Whether in person or remote, assessments should still adhere to recommended opioid safe prescribing procedures (CEP, November 2017).
  • Non‐steroidal anti‐inflammatory drugs (NSAIDs)
  • Steroids
    • Consider the risks (immune suppression, altered immune response, adrenal insufficiency, etc.) and benefits of continued use.
    • Consider the use of a decreased doses if possible.
Top resources
Chronic conditions/disease management
Last reviewed: July 6, 2020
Last updated: July 3, 2020
Diabetes

No evidence that patients with diabetes are at higher risk of contracting COVID-19. (Canadian Healthcare Network, May 9, 2020 [login required]).

During acute illness, patients may be susceptible to adverse drug events due to comorbidities or medicine use. Older adults are at increased risk of adverse events (e.g. kidney), especially if they are also dehydrated, due to age related changes. The following medications (SADMANS) may be of concern in some patients (Can J Diabetes, 2018):

  • Sulfonylureas
  • ACE Inhibitors and angiotensin receptor blockers (ARBs)
  • Diuretics
  • Metformin
  • NSAIDs
  • SGLT2 Inhibitors
Holding diabetes medications
Chronic obstructive pulmonary disease (COPD)

Continued inhaled maintenance therapies. These medications help to minimize risk of a COPD exacerbation and optimize lung function (UpToDate, 2020).

The cautious use of oral prednisone or other systemic corticosteroids (if clinically warranted) to treat acute exacerbations of COPD. The usual guidelines for prompt initiation of systemic glucocorticoids for a COPD exacerbation should be followed, as delaying therapy can increase the risk of a life-threatening exacerbation (UpToDate, 2020). Dosage should be low to-moderate (≤ 0.5–1 mg/kg per day methylprednisolone or equivalent) and duration should be short (≤ 7 days) for exacerbations suspected to be caused by COVID-19 infection (Canadian Thoracic Society, April 8, 2020).

Patients should continue using their oxygen as prescribed and should call 911 if they’re experiencing extreme distress. See the position statement for more information about following manufacturer instructions, the routine cleaning of equipment, and increasing the flow rates of home oxygen. For a list of local respiratory services and equipment, including for home oxygen therapy, see Local Services > Oxygen and respiratory services.

Against the use of nebulized therapy.

For patients who are already using nebulizers at home, they should continue to do so until they discuss switching to an alternative with their family physician/primary care nurse practitioner. Alternatives to nebulized therapy include:

  • Metered dose inhaler (MDI) with spacing device
  • Dry powder inhaler
  • Soft mist inhaler

Approximate equivalent of nebule vs puffers (MDI)

Salbutamol

1 nebule (2.5mg / neb)

4 puffs (100mcg / puff)

Ipratropium

1 nebule (500mcg / neb)

4-8 puffs (20mcg / puff)

See RxFiles’ Table of comparative medication doses for how to manage medication shortages.

In the event of a salbutamol shortage ((beginning April 17th, there has been a shortage in Canada):

Safety of facemasks for patients with underlying lung disease (Canadian Thoracic Society, June 5, 2020):

  • There is NO evidence that wearing a facemask will exacerbate an underlying lung condition.
  • Breathing through a mask takes more effort, which may cause patients to feel short of breath. In such situations, patients should remove the mask, and if symptoms do not immediately settle, they should follow their existing strategy for relief of acute symptoms.
  • If wearing a facemask is not possible despite best efforts, patients should instead avoid or minimize circumstances where physical distancing is not possible.

Consider enrolling patients in Telehomecare for COPD (Ontario Telemedicine Network), a free six-month program that links patients with COPD to Registered Nurses who provide remote monitoring and intensive health coaching.

Asthma

Patients with asthma should restart or continue to use their prescribed inhaled maintenance therapy to improve disease control and to reduce the severity of exacerbations.

There is no current evidence that inhaled corticosteroids increase the risk of acquiring COVID-19 or that they increase the severity of infection.

Prednisone be used to treat severe asthma exacerbations, including those caused by COVID-19 infection. Dosage should be low to-moderate (≤ 0.5–1 mg/kg per day methylprednisolone or equivalent) and duration should be short (≤ 7 days) for exacerbations suspected to be caused by COVID-19 infection.

Biologics should be continued during the COVID-19 pandemic. If biologic therapies are interrupted temporarily, it is suggested to step-up other controller therapies on an individualized basis. Where available, family physicians/primary care nurse practitioners may consider switching patients to self-administration of biologics at home.

Against the use of nebulized therapy.

For patients who are already using nebulizers at home, they should continue to do so until they discuss switching to an alternative with their family physician/primary care nurse practitioner. Alternatives to nebulized therapy include:

  • Metered dose inhaler (MDI) with spacing device
  • Dry powder inhaler

Consult the Canadian Thoracic Society’s 2012 table of comparative ICS medication doses to help guide alternate prescribing in the event of shortages of asthma medications.

In the event of a salbutamol shortage (beginning April 17th, there has been a shortage in Canada):

For a list of local respiratory services and equipment, including for the control of asthma, see Local Services > Oxygen and respiratory services.

Safety of facemasks for patients with underlying lung disease (Canadian Thoracic Society, June 5, 2020):

  • There is NO evidence that wearing a facemask will exacerbate an underlying lung condition.
  • Breathing through a mask takes more effort, which may cause patients to feel short of breath. In such situations, patients should remove the mask, and if symptoms do not immediately settle, they should follow their existing strategy for relief of acute symptoms.
  • If wearing a facemask is not possible despite best efforts, patients should instead avoid or minimize circumstances where physical distancing is not possible.
Cardiovascular disease

Based on current evidence, patients with CVD do not appear to be more likely to acquire COVID-19 infection, however they do appear to be at a greater risk for developing severe COVID-19 if infected (J Med Virol, May 22; Int J Public Health, May 25, 2020).

For patients with known heart failure:

Use telehealth or video conferencing for assessments where possible to limit possible contact with others who may have COVID-19. See the Primary Care Operations in the COVID-19 Context resource for details.

Encourage patients to visit the ER if they experience symptoms or signs suggestive of acute coronary syndrome.

Limit routine blood work unless absolutely necessary, particularly for older adults (≥ 65 years).

Conduct regular follow-up (e.g. every 4 weeks) virtually or by phone with patients who have had cardiac procedures postponed and encourage patients to report any escalation of symptoms.

For cardiovascular medications:

Immunocompromised patients

Immunocompromised patients include (CDC, June 25, 2020):

  • Individuals using immunosuppressant medications.
  • Bone marrow or solid organ transplant recipients.
  • Individuals with inherited immunodeficiency.
  • Individuals living with poorly controlled human immunodeficiency virus (HIV) infection.
  • Patients receiving chemotherapy.

General practices to encourage for immunocompromised patients:

The following risk mitigation options may be considered in consultation with the patient’s specialist (NICE, April 3, 2020, 2020NICE, April 23, 2020NICE, April 9, 2020):

  • Enable virtual or in-home monitoring. See local community services and resources for Homecare in your area.
  • Enable in-home laboratory sample collection. See local community services and resources for Diagnostic centres and laboratories in your area.
  • Reduce the frequency of in-person appointments.
  • Increase the time interval between blood tests in patients who are stable on treatment (taking age and comorbidities into account).
  • Modify dose, treatment schedule, and/or administration protocol to reduce the need for hospital attendance (including use of community outreach teams if available) and/or reduce the likelihood of subsequent hospital admission.

Immunocompromised healthcare providers must make decisions that reflect their own unique situations, while also considering public health advice and the best available evidence (CPSO, May 26, 2020).

Top resources
Older adults
Last reviewed: July 6, 2020
Last updated: June 5, 2020
Managing chronic conditions

Older adults are at increased risk of adverse events (e.g. kidney), especially if they are also dehydrated, due to age related changes.

See Chronic conditions/disease management for information to help manage individual older adult patients with chronic conditions.

Immunization guidance

Avoid asking older adults to visit a clinic only for vaccinations at this time. However, if the opportunity arises, please vaccinate.

If possible offer immunization when it can be combined with another medical visit. Offer multiple vaccines if required in order to minimize the risk of acquiring COVID-19 and to reduce the number of health care encounters (Government of Canada, May 13, 2020).

Ages 65+: Pneumococcal (pneu-C13 & penu-P23).

It may be possible to adjust the timing of scheduled vaccines as long as the injection series is eventually completed (Canadian Pharmacist Association, March 26, 2020).

For adults 50+ who have received the first dose of recombinant zoster vaccine, the second dose can be deferred until the 6-12 month interval (doses are typically recommended 2-6 months apart, and may be considered up to 12 months apart) assuming that COVID-19 risk will be lower by that time.

If an interval longer than 6-12 months after the first dose has elapsed, the vaccine series does not need to be restarted; the decision when to complete the series should take into consideration the local COVID-19 community transmission risk, recognizing that individuals may remain at risk of herpes zoster during a longer than recommended interval between doses 1 and 2 (Government of Canada, May 13, 2020).

Consult the Canadian Immunization Guide (Government of Canada, 2017) for more detailed guidance on specific vaccines.

Top resources
Opioid use disorder (OUD)
Last reviewed: July 6, 2020
Last updated: June 25, 2020

This tool has been developed to support primary care providers in navigating and providing patient care in a world where COVID-19 is the ‘new normal’, with considerations and recommendations on what’s ‘new’ and what’s ‘changed’ in the delivery of care for patients living with OUD.  While how care is delivered has changed, efforts should be made to ensure that the quality has not. As always, when treating your patients, continue to use your clinical judgement and follow standards of care, best practices, evidence and guidelines.

Prenatal and postnatal care
Last reviewed: July 6, 2020
Last updated: June 23, 2020
Prenatal care

Remote visits should be offered where appropriate. Recent literature supports some reduction in frequency of visits in the later trimesters if the first trimester screening indicates a low-risk pregnancy (SOGC, April 6, 2020).

During the pandemic, nuchal translucency (NT) ultrasound may be unavailable due to service reductions or patients being in self-isolation. In this circumstance, second trimester MSS Quad is recommended (Prenatal Screening Ontario, 2020). For additional guidance, see Important Prenatal Screening Service Announcement for Health Care Providers (Prenatal Screening Ontario, April 6, 2020).

Postnatal care
When checking in on new parents, ask about their mental health and support system and connect them with local resources. For local community services and resources that you can connect your patients to, see the CEP’s Local Services Resource for:

For information on well-child visits and immunizations, see Routine child care.

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Routine child care
Last reviewed: July 6, 2020
Last updated: June 23, 2020

Cloth face coverings are not recommended for children under 2 years of age, and face shields for newborns and infants are not recommended because of the risk of accidental suffocation or strangulation (CDC, June 25, 2020).

Due to increased risk of accidental contact with the eyes and mouth, caution must be taken when hand sanitizers are within reach of young children, and when being used by or around children. For specific guidance, see Hand sanitizers: Promoting safe use by children (CPS, April 20, 2020).

Screening for travel risk and symptoms should take place before in-person visit, and symptomatic caregivers should be discouraged from accompanying children to the office, clinic, or other healthcare setting (CPS, March 25, 2020). See the Primary Care Operations in the COVID-19 Context resource for details on delivering patient care remotely and in person.

Early introduction of allergenic foods for at-risk infants (due to eczema, other food allergy, or an immediate family history of allergies) is still recommended during the COVID-19 pandemic. The risk of a severe allergic reaction on first ingestion of an allergen in infancy is extremely low (CPS, April 15, 2020).

Well child visits
Immunizations

Routine childhood immunizations should be kept up to date through in-person visits, since delay or omission could put children at risk for common and serious childhood infections (CPS, April 30, 2020).

In some jurisdictions where public health capacity has been severely limited by the pandemic, delaying booster doses while providing parents with catch-up plans before re-opening schools and child care settings may be reasonable (CPS, April 29, 2020).

A Children’s Immunization Clinic will operate every Tuesday-Thursday at the Children’s Hospital of Eastern Ottawa for children < 2 years of age in the Ottawa region who are unable to get their routine first series of immunizations due to COVID-19 closures.

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Social care guidance
Last reviewed: June 10, 2020
Last updated: June 10, 2020

During pandemics, historically marginalized and minoritized individuals suffer disproportionately. The Centre for Effective Practice (CEP), in partnership with Upstream Lab and the Department of Family and Community Medicine at the University of Toronto, developed the COVID-19: Social Care Guidance to assist health and social care providers as they support individuals exposed to COVID-19-related social risks that impact health.

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