COVID-19 in 2024: Care and Operations Guidance

Last Updated: June 28, 2024

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Please note that as of July 5, 2024, this resource will no longer be updated. For the latest clinical recommendations, coverage updates, and treatment information, please visit Ontario Health COVID-19 Clinical Resources.

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Isolation requirements New

Please note that as of July 5, 2024, this page will no longer be updated. For the latest clinical recommendations, coverage updates, and treatment information, please visit Ontario Health COVID-19 Clinical Resources.

Isolation requirements (MOH, Dec 19, 2023)
If you have symptoms of COVID-19

Stay at home and self-isolate until all of the following apply:

  • your symptoms have been improving for at least 24 hours (or 48 hours if you had nausea, vomiting and/or diarrhea)
  • you do not have a fever
  • you do not develop any additional symptoms

Once symptoms are improving and you are no longer self-isolating at home, the following can provide extra protection against the spread of COVID-19.

 

For 10 days after your symptoms started:

  • Self-monitor for symptoms and self-isolate if they develop any symptom of COVID-19
  • Wear a tight-fitted, well-constructed mask in all public settings
  • Avoid non-essential activities where you need to take off your mask (e.g., dining out)
  • Avoid non-essential visits to anyone who is immunocompromised or may be at higher risk of illness (e.g., seniors)
  • Avoid non-essential visits to highest risk settings in the community such as hospitals and long-term care homes
  • Where visits cannot be avoided, wear a mask and recommend the individual being visited also wear a mask
If you are
immunocompromised

If you are immunocompromised and test positive for COVID-19 or have not been tested, you should stay home for 10 days and follow guidance on COVID-19 testing and treatment as you may benefit from available therapies to prevent severe illness.

 

If you test negative for COVID-19, you can stop isolating at home once your symptoms are improving for at least 24 hours (or 48 hours if you had nausea, vomiting and/or diarrhea) and you do not have a fever.

 

You can then take additional precautions for up to 10 days after your symptoms started as extra protection against the spread of COVID-19 and other respiratory viruses circulating in the community.

If you work in high-risk setting

If you have symptoms of COVID-19 or have tested positive for COVID-19 and work in a high-risk setting (such as a hospital, a long-term care home, or a retirement home), you should speak with your employer and follow your workplace guidance for return to work.

PPE and IPAC considerations 2024 New

Please note that as of July 5, 2024, this page will no longer be updated. For the latest clinical recommendations, coverage updates, and treatment information, please visit Ontario Health COVID-19 Clinical Resources.

COVID-19 vaccines 2024 New

Please note that as of July 5, 2024, this page will no longer be updated. For the latest clinical recommendations, coverage updates, and treatment information, please visit Ontario Health COVID-19 Clinical Resources.

Vaccine guidance

In Spring 2024, individuals who are at increased risk of severe illness should receive an additional dose of an XBB COVID-19 vaccine. Eligible individuals include

  • Adults 65 years of age and older
  • Adult residents of long-term care homes and other congregate living settings for seniors
  • Individuals 6 months of age and older who are moderately to severely immunocompromised (due to an underlying condition or treatment
  • Individuals 55 years and older who identify as First Nations, Inuit, or Metis and their non-Indigenous household members who are 55 years and older.

Eligible individuals may receive an XBB COVID-19 vaccine in Spring 2024 if it has been 6 months from the previous dose or known COVID-19 infection.  

All other individuals are not currently recommended to receive an additional COVID-19 vaccine dose in Spring 2024. This includes individuals who are not at a higher risk of severe illness who did not receive an XBB COVID-19 vaccine in Fall 2023, unless they are specifically recommended to by their health care provider (MOH, 2024).

Moderna XBB.1.5 COVID-19 vaccine recommendations

Unvaccinated
2 doses: 25 mcg

1 or more previous doses
1 dose: 25 mcg

Vaccinated or unvaccinated
1 dose: 25 mcg

Vaccinated or unvaccinated
1 dose: 50 mcg

Pfizer XBB.1.5 COVID-19 vaccine recommendations

Unvaccinated
3 doses:  3 mcg

Vaccinated
1 dose received
2 doses: 3 mcg 

2 doses of received
1 dose: 3 mcg 

Vaccinated or unvaccinated
1 dose: 10 mcg

Vaccinated or unvaccinated
1 dose: 30 mcg

Novavax XBB.1.5 COVID-19 vaccine recommendations

Unvaccinated
2 doses: 5 mcg, 21 days apart

Vaccinated
1 dose: 5 mcg

For more information on vaccine storage & handling and further resources to support immunization, please visit the Ministry of Health’s page on the Ontario COVID-19 Vaccine Program.

Timing of other vaccinations

Individuals 6 months and older can receive a COVID-19 vaccine before, after, or simultaneously with other vaccines (i.e., non-COVID-19 vaccines). This includes both live and non-live vaccines. Patients should be informed of the benefits and risks, given the limited data available on administration of COVID-19 vaccines at the same time as, or shortly before or after, other vaccines. In the case of co-administration, individuals should be immunized on separate arms to minimize the risk of interaction.  

Exceptions:

Imvamune (mpox):  A 4-week interval is recommended either before or after receiving a COVID-19 vaccine. If needed, individuals should receive the Imvamune vaccine pre- and post-exposure, regardless of the timing of a COVID-19 vaccine. 

Arexvy (RSV): Individuals should wait at least 2 weeks before or after administration of the RSV vaccine before receiving a COVID-19 vaccine. Please refer to the Ministry’s website on RSV for more information. 

COVID-19 vaccines and consent for children and youth under 18

Consent requirements differ between Public Health Units, with some requiring parental consent but not others. 

In Ontario, there is no defined age of consent for vaccinations. Generally, children can consent to medical treatments as long as they are deemed capable of making an informed decision. This means that they must be able to understand information about the vaccine and what will happen if they accept or refuse vaccination. Children should talk about the benefits and risks of getting the vaccine with a trusted caregiver and their health provider.  

For a more detailed overview, see CMPA’s updated “Vaccination” section (May 2023).

Outpatient management of patients with COVID-19

Please note that as of July 5, 2024, this page will no longer be updated. For the latest clinical recommendations, coverage updates, and treatment information, please visit Ontario Health COVID-19 Clinical Resources.

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Who can be managed at home?

Patients can safely self-manage at home if they have mild to moderate symptoms of COVID-19 and do not have any co-morbid conditions or complications (HFAM, 2023).

Who should be hospitalized?

Instruct patients to seek an urgent follow-up assessment with their family physician or hospitalization if they experience any of the following red flag symptoms (HFAM, 2023):

  • Severe shortness of breath at rest (e.g. Breathlessness RR >30 despite normal O2 sats)
  • Difficulty in breathing (work of breathing)
  • Reducing O2 saturation
  • Pain or pressure in chest
  • Decreased oral intake or urine output (dehydrated, needing IV fluids)
  • Low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)  
  • Cold, clammy or pale mottled skin
  • New onset of confusion, becoming difficult to rouse, syncope
  • Blue lips or face
  • Coughing up blood

Monitor other symptoms possibly associated with COVID-19, including:

  • Abdominal pain
    • Not related to other known causes or conditions (e.g., menstrual cramps, gastroesophageal reflux disease)
  • Conjunctivitis (pink eye)
    • Not related to other known causes or conditions (e.g., blepharitis, recurrent styes)
  • Decreased or lack of appetite
    • For young children and not related to other known causes or conditions (e.g., anxiety, constipation)

For patients experiencing a more severe case of COVID-19 and cannot safely self-monitor at home (but not experiencing red flag symptoms), consider close monitoring by a family physician or refer to an open Clinical Assessment Centre (CAC).

Managing patients at home

For patients with symptoms compatible with COVID-19 and those who have tested positive for COVID-19 (HFAM, 2023):

  • Counsel all patients about self-monitoring for red flag symptoms of worsening disease (see Who should be hospitalized?) and provide clear guidance on who to call.
  • Assess patients for pre-existing conditions that may put them at a higher risk of deterioration and monitor these patients closely. See Symptom management and comorbid considerations.
  • Provide treatment as necessary to patients with COVID-19. For information on recommended treatment and evidence see Therapeutic management of mild COVID-19.
  • Determine an appropriate follow-up frequency based on the patient’s risk for severe disease, severity of respiratory symptoms, and your comfort level with their ability to self-report worsening symptoms (HFAM, 2023).
    • For patients assessed at low risk, consider self-monitoring only with check-ins determined by individual patient;
    • For patients assessed at average risk, monitor every few days for 7 days, then recommend self-monitor for additional 7 days spending on progress;

For more guidance, see Assessment, Monitoring and Management of COVID (HFAM, 2023).

For patients assessed at high risk, monitor daily for 7 days, then every few days depending on progress until symptoms resolve.

Therapeutic management of mild COVID-19

The following recommendations apply to adult patients who do not require new or additional supplemental oxygen from their baseline status.

Below is a general pathway for how primary care providers can access outpatient therapies for people at higher risk of severe disease, specifically remdesivir and Paxlovid. Local pathways may vary based on availability of services and pre-existing pathways.

Pathway to accessing outpatient therapies

Proactively inform potentially eligible patients to contact a health care professional if they develop symptoms of COVID-19. This is done during appointments, via email or telephone, or by updating the practice’s website or online booking portal.  See I think I have COVID. When should I call my doctor? for a handout to give patients at higher risk of severe disease.

  • 60 years of age or older
  • 18 years of age or older and are immunocompromised
  • 18 – 59 years old and at a higher risk of severe COVID-19 including having:
    • one or more underlying medical conditions (such as diabetes, heart or lung disease), or
    • inadequate immunity against COVID-19 from:
      • not receiving a full primary series of the COVID-19 vaccine
      • having received a full primary series but no COVID-19 vaccine or COVID-19 infection within the past six months
  • Indigenous people, Black people, and members of other racialized communities may be at increased risk of disease progression due to disparate rates of comorbidity, increased barriers to vaccination, and social determinants of health. They should be considered priority populations for access to COVID-19 drugs and therapeutics.

Pathway to accessing outpatient therapies

Try to connect virtually or in-person with patients at higher risk of severe disease who have developed symptoms of COVID-19 within 24 hours of the patient seeking support.

Assess the patient and determine an appropriate treatment course, considering patient eligibility and contraindications and local availability of therapies. See Recommended drugs for patients with mild COVID-19.

Follow-up provided after treatment will vary depending on local arrangements and may include handoff back to primary care for ongoing monitoring (e.g., via COVID@Home). See Assessment, monitoring and management of COVID-19: Monitoring and follow-up (tab 6) for information on monitoring and follow-up based on risk level.

Recommended drugs for patients with mild COVID-19

While evidence is still emerging, prescribers should feel confident that Paxlovid is effective for patients at high risk of severe COVID-19 when initiated within the first 5 days of symptom onset. Evidence suggests continued efficacy in the latest Omicron subvariants.

Due to increased supply, Paxlovid is now available in community pharmacies and can be prescribed by a pharmacist. There is no cost to patients and no health care is required.

Role in therapy
  • Recommended for patients with mild to moderate COVID-19 at higher risk of severe disease who present within 5 days of symptom onset.
    • May be considered in pregnant or lactating patients if the benefits of treatment outweigh the potential risks.
  • Indicated for the treatment of mild-to-moderate coronavirus disease (COVID-19) in adults with positive results of direct severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death.
  • For more information, see Nirmatrelvir/Ritonavir (Paxlovid): What Prescribers and Pharmacists Need to Know.

Assessing eligibility and appropriateness

Paxlovid is intended for patients with mild to moderate COVID-19 who are not on supplemental oxygen but are at risk of progressing to severe COVID-19 infection. Primary care clinicians should engage in shared decision-making with every confirmed COVID-positive patient eligible for Paxlovid.

To be eligible for Paxlovid, patients must:

  • have tested positive for COVID-19 by PCR, rapid molecular or rapid antigen test. At-home rapid antigen test with provider verification is acceptable (in-person, virtual, picture or video) AND
  • be within 5 days of symptom onset (symptom onset is considered day 0)

Paxlovid should be strongly considered for individuals in these categories:

  • 60 years or older
  • Living with comorbidities: See Health Canada’s list of underlying medical conditions associated with more severe COVID-19 disease
  • Those with lowered Immune status: Either unvaccinated or with an incomplete primary series, or completed primary series with last COVID-19 vaccine dose more than 6 months ago AND last COVID-19 infection more than 6 months ago
  • Groups with poorer COVID-19 outcomes including Indigenous people, Black people and other members of racialized communities, Individuals with intellectual, developmental, or cognitive disability, people who use substances regularly, who live with mental health conditions, and who are underhoused
Dosage, cost and administration
  • Normal renal function: 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet), with all three taken together orally twice daily for 5 days.
  • Mild-moderate renal impairment (eGFR 30-60 mL/min): 150 mg nirmatrelvir (one 150 mg tablet) with 100 mg ritonavir (one 100 mg tablet), taken together orally twice daily for 5 days.
  • Not recommended for patients with severe renal impairment (eGFR <30 mL/min) or severe hepatic impairment.
Adverse effects
  • Altered sense of taste, diarrhea, muscle pain, vomiting, high blood pressure, headache.
Key drug interactions
  • Contraindicated in patients taking drugs that are:
    • Highly metabolized by CYP3A4 where elevated concentrations can be life-threatening
    • Potent CYP3A4 inducers which may reduce the effectiveness of nirmatrelvir/ritonavir and contribute to the development of drug resistance.
  • Nirmatrelvir/ritonavir have many drug interactions. See Nirmatrelvir/Ritonavir (Paxlovid): What Prescribers and Pharmacists Need to Know
Role in therapy
  • Recommended as an alternative to Paxlovid for patients with mild COVID-19 at higher risk of severe disease who present within 7 days of symptom onset.
  • Recommended for patients who cannot take Paxlovid due to contraindication (medical contraindication or drug interaction that cannot be safely managed) or >5 days after symptom onset.
  • Available evidence indicates similar effectiveness to Paxlovid.
Dosage, cost and administration
  • 200 mg IV x 1 day, then 100 mg IV daily x 2 days.
  • Price of drug in Canada currently not publicly available. Administration costs must also be considered.
Adverse effects
  • Allergic reaction or infusion reaction (rare): changes to blood pressure or heart rate, low blood oxygen levels, high temperature, shortness of breath or wheezing, swelling of face, lips, tongue or throat, rash, nausea, sweating, shivering.
  • Infusion site reaction: Pain, bruising swelling or redness at the infusion site.
  • Other adverse events: increased transaminases, nausea, headache, rash
Key drug interactions
  • Avoid use with:
    • Chloroquine and hydroxychloroquine (antagonize the effects of remdesivir)
    • Drugs which reduce renal function
    • Strong inducers of CYP450 (e.g., rifampinin)
  • The potential for drug interactions with inhibitors inducers of CYP2C8, 2D6 or 3A4 (remdesivir is a substrate of these enzymes) has not been studied.

Effective 2023-24, the Ontario Ministry of Health has established community-based ways for individuals to access Remdesivir as a treatment for COVID-19 through Home and Community Care Support Services (HCCSS). Refer patients to their local HCCSS branch for a nurse to administer Remdesivir infusions. Please note, in Northern Ontario, hospitals and assessment centres continue to operate and provide COVID-19 assessments in the majority of communities.

For more information please visit Ontario Health: COVID-19 Health System Response Materials

Symptom management

Potential management strategies (NICE, November 30, 2023)

  • Drink fluids regularly (no more than 2 litres/day).
  • Take paracetamol or ibuprofen if a patient has a fever and other symptoms antipyretics help treat.

Potential management strategies (NICE, November 30, 2023)

  • Avoid lying on back (makes coughing ineffective).
  • A teaspoon of honey.
  • Only if cough is distressing, short-term, limited supply prescription for codeine linctus, codeine phosphate tablets or morphine sulfate oral solution may be considered.

Potential management strategies (NICE, November 30, 2023)

  • Keep the room cool.
  • Encourage relaxation and breathing techniques (positioning, pursed-lip breathing, breathing exercises and coordinated breathing training).
  • Improve air circulation by opening a window or door (avoid using a fan because this can spread infection).

Post COVID-19 condition

Please note that as of July 5, 2024, this page will no longer be updated. For the latest clinical recommendations, coverage updates, and treatment information, please visit Ontario Health COVID-19 Clinical Resources.

What is “post COVID-19 condition”?

Post COVID-19 condition (or long COVID) includes a wide range of symptoms following a probable or confirmed history of a severe, mild or asymptomatic COVID-19 infection usually occurring beyond 12 weeks (Ontario Health, December 2022). 

Common symptoms
  • Dyspnea or increased respiratory effort
  • Cough
  • Fatigue/malaise 
  • Decreased mobility 
  • Fever
  • Menstrual cycle irregularities 
  • Insomnia
  • Memory deficits
  • Difficulty concentrating 
  • Headaches
  • Dizziness
  • Paresthesia 
  • Joint Pain
  • Muscle pain 
  • Anxiety
  • Depression
  • Abdominal pain
  • Diarrhea  
  • Loss of taste or smell 
  • Skin rashes

Patient evaluation for suspected post COVID-19 condition

To avoid over investigation, consider a conservative diagnostic approach in the first 4 to 12 weeks after COVID-19 infection. Currently, there are no definitive tests to determine the presence of post COVID-19 condition. Consider laboratory tests based on patient history, physical examination and clinical findings. Tailor testing to a person’s signs and symptoms to understand if they are caused by an ongoing case of COVID-19, post-COVID 19 condition or an unrelated diagnosis (Ontario Health, December 2022).

As multiple organ systems are possibly involved in post COVID-19 condition, a thorough physical examination is recommended (Ontario Health, December 2022).

Reminder for providers to convey empathy, listen and validate 

It is important to approach patients possibly dealing with post COVID-19 condition with empathy, listen to what symptoms they are experiencing, and validate what they are going through (NICE, November 11 2022). Many patients report feeling like their symptoms are not taken seriously or they do not realize that what they are experiencing is connected to COVID-19, making a holistic approach to assessment highly important (NICE, November 11 2022).

Evidence indicates that post-COVID 19 condition can cause a new onset of Postural Orthostatic Tachycardia Syndrome (POTS). For more information on diagnosing, assessing, and managing POTS, please visit CEP’s POTS tool (PNAS, 2021; Nature, 2023; Expert Opinion).

Symptoms of post-COVID 19 condition can overlap with symptoms of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). There is also emerging evidence to suggest that post-COVID 19 condition can cause a new onset of ME/CFS. For more information on diagnosing, assessing, and managing ME/CFS, please visit CEP’s ME/CFS tool (PNAS, 2021; Nature, 2023; Expert Opinion).

Guidance for how to help patients recover

The primary recommendation for managing patient recovery is self-management and supported self-management through several techniques. It is important to note that care plans are recommended to be developed using a shared decision making approach, ensuring that the patient’s preferences, support network, and goals are taken into account to create a management plan that works best for them (NICE, November 11 2022). 

  • Encouraging patients to keep diaries or calendars that document their symptom severity and any changes to health conditions. This can help identify any possible triggers such as physical exertion, medical treatments, medications, or menstruation. Examples include mood diaries which can aid in the screening and diagnosis of related or comorbid mental health conditions. 
  • Develop a comprehensive plan based on patient symptoms that incorporates their treatment goals. 
  • Consider providing referrals to other support services such as home care, mental health support, employment, housing, or financial support depending on patient needs. Patients can also be directed to call 211 to be referred to relevant social service supports. 
  • Provide education and support materials for at-home self-care including nutrition, physical activity, sleep, stress, and chronic disease management. See “Self-management techniques for symptoms” tips below. 
  • If initial symptoms are moderate to severe, or continue worsening in severity, consider a referral to an interdisciplinary rehabilitation program or a relevant specialist. Note that COVID-19 and Post-COVID Condition advice is available through eConsult.
  • Consider providing resources to support caregivers. 
  • Consider supporting an application for short or long term disability income support if unable to work or if work hours are reduced. 
Self-management techniques for symptoms: 

There are many health promotion education resources available to share with patients when developing their self-management care plan. Consider the following resources and guidance: 

What to do if patients aren’t getting better

In the case that patients are not getting better through self-management recovery, it may be beneficial to suggest participation in a rehabilitation program available in their area. A list of post-COVID-19 rehabilitation clinics in Ontario is available through the Rehabilitative Care Alliance. 

Research trials

How to support patients completing disability applications

The Prosper Benefits Wayfinder produces an individualized list of income supports. Steps to Justice provides guides to income assistance.  Key programs include:

Disability support programs generally look toward impact on day to day life and function as opposed to medical proof of diagnosis.

Reminder, presentation of post COVID-19 condition symptoms can look different from patient to patient and can present on different timelines. It is important to keep this in mind when assessing for post COVID-19 condition and providing corresponding documentation for disability claims. 

Palliative care and COVID-19 New

Please note that as of July 5, 2024, this page will no longer be updated. For the latest clinical recommendations, coverage updates, and treatment information, please visit Ontario Health COVID-19 Clinical Resources.

The role of primary care

To help address palliative care services related to COVID-19, family physicians and community palliative care nurse practitioners will have to:

Navigate difficult conversations with patients, families and caregivers and identify the patient’s goals of care

Providers need to ensure the patient understands the nature and severity of their illness, and explore their goals of care to support decision-making and enable person-centred care.

Document decisions regarding do not resuscitate (DNR)

Manage symptoms, and address other palliative care needs for patients with COVID-19

Family physicians and community palliative care nurse practitioners need to be prepared to address the palliative care needs of their COVID-19 patients. Dyspnea, delirium, nausea and vomiting, and pain will be particularly relevant for patients with COVID-19.

Provide end-of-life care for COVID-19 patients

When patients with COVID-19 are in their final weeks and days of life, family physicians and community palliative care nurse practitioners need to be prepared to support and provide end-of-life care.

  • It is important to ensure rapid access to palliative medications that are often at higher doses than seen in standard practice
  • Dose ranges should be considered to allow for urgent decision-making regarding escalation of dose for distressing symptoms.
  • The most common terminal symptoms (fever, rigors, severe dyspnea, cough, delirium and agitation) can develop rapidly and be distressing.

Provide grief and bereavement support

For many people, the time following the death of a loved one can be filled with a range of emotions and physical reactions. It is important in the grief journey that people are able to openly talk about these experiences, reactions and feelings. Providers can recommend the following resources for those who have lost a loved one:

  • Bereaved Families of Ontario for group support, one-to-one sessions and telephone support.
  • MyGrief.ca, an online resource that can help one understand their grief and work through some of the difficult issues they may be facing.
  • Kidsgrief.ca, a free online resource that helps parents support their children when someone in their life is dying or has died.
  • Connect grieving individuals to local services for mental health and counselling support.