Primary Care Operations in the COVID-19 Context

All sectors are encouraged to:

• Work with Chief Regional Officers and regional tables to coordinate and support local surge capacity (this includes enhanced Health Human Resource Response/Models of Care tables).
• Partner regionally to support timely access to care for patients.
• Implement strategies to maximize influenza and bivalent COVID-19 vaccine uptake among health care workers.
• Encourage patients to use Health Connect Ontario for non-urgent health advice. Registered nurses are available 24/7 via telephone (811) or online chat at ontario.ca/HealthConnectOntario.

Within primary care and community support services, it is important to:

• Stay connected to both your local Ontario Health Team and your local public health unit, as well as maintain an awareness of provincial COVID-19 trends to best serve patients. See COVID-19 Data and Surveillance (PHO) for the latest information.
• Continue delivering timely immunization, early identification, and referral of patients who would benefit from COVID-19 therapies (e.g., Paxlovid).
• Support emergency department diversion by prioritizing care for children and adults with COVID-19, influenza, and other respiratory illnesses.
• Continue to focus on preventative care (e.g., cancer screening) and the provision of comprehensive primary care.

Ensure community support service organizations continue to participate and collaborate on regional response and recovery efforts. (Ontario Health, November 1, 2022).

• Consider testing eligible patients in-office. See Testing and isolation requirements.
• Evusheld is currently available to select immunocompromised patients through specialty clinics, including cancer centres and transplant sites. See Ontario Health Recommendation on the Use of Evusheld for more information..
• See Guidance for the prescription of nirmatrelvir/ritonavir (Paxlovid).

CACs can test, assess and provide treatment options for individuals who have cold-like or flu-like symptoms, a known or suspected respiratory illness or influenza-like illness (ILI), or a known or suspected case of COVID-19. A search on the CAC website will provide details about each centre, including whether pediatric testing and/or assessment is available in a particular geographic area.

• See Clinical Assessment Centres (CACs): Information for Primary Care Providers for more information on eligibility, locations, referral process and services provided.

COVID-19 vaccination

• See Vaccine rollout in Ontario for information on vaccine eligibility, including 4th doses
• See Vaccination in primary care for guidance on offering vaccinations in primary care and identifying eligible populations in your practice

Influenza vaccination

• If vaccinating patients in your practice, take the opportunity to immunize patients and their accompanying persons when they are seen for other reasons (including COVID-19 vaccination) and during home care visits.
• High-priority populations for vaccination include:
  • • Anyone who is at high risk of severe COVID-19 related illness:
      • Older adults, especially over 65. See AVOID frailty (Canadian Frailty Network, 2020) for more information on the importance of vaccines in frail older adults
      • Those with chronic medical conditions
      • Those who are immunocompromised, with an underlying medical condition or taking medications that lower the immune system
      • People living with obesity (BMI of 40 or higher)
  • Anyone who is capable of transmitting influenza to those at high risk of severe and critical illness related to COVID-19, such as those with high-risk family members, or caregivers of high-risk individuals
  • Essential workers: health care workers, teachers, bus drivers, retail workers, grocery store clerks, etc.

• Multiple vaccinations can be given at the same time, but you must follow Ontario’s immunization schedule.
• For individuals 5 years of age and older, COVID-19 vaccines may be given concurrently with non-COVID-19 vaccines (including live and non-live vaccines). There is no required time interval before or after (MOH, December 20, 2022).
• Many local public health units are running catch-up clinics for students who may have missed school-based immunizations and patients can be directed there
• Vaccines for school distribution can also be ordered by primary care practices through standard vaccine ordering processes of local public health units

For more information on where to get your flu shot, please click here. Two enhanced products are specifically indicated for those 65 years and older (a high-dose quadrivalent and an adjuvant trivalent), noting that all products protect against influenza and patients should not delay vaccination to wait for a particular product (Ontario Health, November 3, 2022).

• If you are vaccinating patients in your practice, provide immunization to patients and their accompanying persons when they are seen for other reasons (including COVID-19 vaccination) and during home care visits.
• Concerted efforts should be made to vaccinate:
  • Anyone who is at high risk of severe COVID-19 related illness:
    • Older adults, especially over 65. See AVOID frailty (Canadian Frailty Network, 2020) for more information on the importance of vaccines in frail older adults.
    • Those with chronic medical conditions (lung disease, heart disease, diabetes, hypertension, etc.)
    • Those who are immunocompromised, with an underlying medical condition or taking medications that lower the immune system
    • People living with obesity (BMI of 40 or higher)
  • Anyone who is capable of transmitting influenza to those at high risk of severe and critical illness related to COVID-19, such as those with high-risk family members, or caregivers of high-risk individuals
  • Essential workers: health care workers, teachers, bus drivers, retail workers, grocery store clerks, etc.

While evidence of the impact of influenza antivirals on patient outcomes is still limited, they have been shown to decrease the duration of symptoms and to reduce severity and complications such as hospitalization and death. AMMI (2019/2021-22), PHO (2022), and OH (COVID-19 System Response Materials) recommend the use of antivirals such as oseltamivir (Tamiflu, generics) in certain community settings to reduce the spread and severity of seasonal influenza.

Tamiflu vs Relenza

This content exclusively covers Tamiflu. While both Tamiflu (oseltamivir) and Relenza (Zanamivir) are included in the recent PHO guidance (PHO 2022), the recent LU code extension applies only to Tamiflu.

Health Canada recommends Tamiflu over Relenza due to its oral administration, use with all age groups, and status as the drug of choice for pregnant women and patients with severe/progressive clinical illness. There is a greater body of evidence supporting Tamiflu than Relenza. Relenza can be used as a substitute for patients 7 years and older without contraindications.  From Antiviral Annex: Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector (Health Canada)

To support the use of oseltamivir in community settings, a new Limited Use (LU) Code will be in effect for oseltamivir as of Nov. 30, 2022 to improve access for patients outside of LTC/RH. The new LU code is only in effect for the 2022–2023 influenza season.

LU Authorization Period: 6 months

Code 639: For treatment of individuals at high risk* of complications from influenza infection who have either:

• Laboratory-confirmed influenza A or influenza B infection OR
• Illness consistent with influenza A or influenza B infectionThe full LU criteria are available through the online ODB Formulary at: Formulary Search (gov.on.ca) and are also outlined in the ODB Formulary November 2022 Summary of Changes document (see pages 8–10).

Antivirals are recommended when all of the following conditions are met:

1. Influenza is circulating in the community. Consult Public Health Ontario’s Ontario Respiratory Pathogen Bulletin or your local public health unit.
2. The patient has symptoms of influenza-like illness (ILI), including: sudden onset of fever, cough, headache, sore throat, muscle aches, and fatigue. Note: Fever may be absent in older adults.
3. The patient is at high risk for complications of influenza and/or has moderate, progressive, or severe influenza.

Tips for initiation

• Antiviral medications work best if administered within 48 hours of symptom onset.
• Antiviral treatment should still be initiated beyond 48 hours in severely ill individuals and for those with progressive, severe, or complicated illness or risk factors for complications of influenza (i.e. those needing oxygen.) May not apply in community settings unless patient declines to go to ER.
• When influenza is circulating in the community antiviral treatment should be started as soon as possible without waiting for laboratory-confirmation of influenza. Clinicians do not need to initiate testing to prescribe or bill for Tamiflu.
• For those presenting within 48 hours of symptom onset but without risk factors for complications and/or serious illness:
  • Patients 18-64 years of age: Antiviral treatment can be considered but not routinely recommended in absence of other risk factors.

High risk conditions

• Asthma and other chronic pulmonary disease, including bronchopulmonary dysplasia, cystic fibrosis, chronic bronchitis, and emphysema
• Cardiovascular disease (excluding isolated hypertension; including congenital and acquired heart disease such as congestive heart failure and symptomatic coronary artery disease)
• Malignancy
• Chronic renal insufficiency
• Diabetes mellitus and other metabolic diseases
• Hemoglobinopathies such as sickle cell disease
• Immunosuppression or immunodeficiency due to disease (e.g., HIV infection, especially if CD4 is < 200 × 106 /L) or iatrogenic, due to medication
• Neurological disease and neurodevelopmental disorders that compromise handling of respiratory secretions (cognitive dysfunction, spinal cord injury, seizure disorders, neuromuscular disorders, cerebral palsy, metabolic disorders)
• Indigenous peoples
• Children aged younger than 5 years. Children aged 2–4 years have a higher rate of complications than older children; children < 2 years have the highest risk
• Individuals aged 65 years or older
• People of any age who are residents of nursing homes or other chronic care facilities
• Pregnant people and people up to 4 weeks postpartum regardless of how the pregnancy ended.The risk of influenza-related hospitalization increases with length of gestation; ie, it is higher in the third trimester than in the second
• Individuals aged younger than 18 years who are on chronic aspirin therapy
• Obesity with a BMI ≥40 or a BMI >3 z-scores above the mean for age and gender
• Children and adolescents (age 6 months–18 years) undergoing treatment for long periods with acetylsalicylic acid because of the potential increase in Reye’s syndrome associated with influenza

From AMMI (2019), Ontario Drug Benefit formulary (Edition 43)

Contraindications

Tamiflu is contraindicated in patients who are hypersensitive to the drug or any ingredient in the formulation, including any non-medicinal ingredient or component of the container. For a complete listing see Tamiflu Product Monograph (2022).

Treatment

From: AMMI (2019)

Antivirals are not authorized in Canada for the routine treatment of seasonal influenza illness in infants aged younger than 1 year. The efficacy of Tamiflu in infants younger than 1 year of age has not been established. Use may be considered on a case-by-case basis.

From: AMMI (2019)

Pre vs. post-exposure prophylaxis

Detailed guidance on prophylaxis

Pre-exposure prophylaxis can be considered for the following scenarios during community outbreaks of influenza:

• As a bridge to vaccine-induced immunity during the 14-day period after immunization of high-risk individuals when inactivated vaccine is used
• Protection of high-risk persons for whom vaccination is contraindicated or deemed likely to be ineffective
• Protection of high-risk patients and their family members/close contacts when circulating strains of influenza virus are not matched with trivalent or quadrivalent seasonal influenza vaccine strains,
• Protection of family members or health care workers for whom influenza immunization is contraindicated, and who are likely to have ongoing close exposure to unimmunized persons at high risk, including infants and toddlers aged younger than 24 months

Post-exposure prophylaxis may be considered for persons who cannot be reliably protected by immunization:

• When initiated in the first 48 hours after exposure to a contact with suspected or lab-confirmed influenza.
• To control outbreaks in closed facilities, antiviral drug prophylaxis, combined with treatment and inactivated vaccine administration, is indicated

Neither early treatment nor PEP should be prescribed:

• For groups of healthy individuals on the basis of possible exposure in the community
• If the close contact did not occur during the infectious period (from 1 day before the onset of symptoms until 24 hours after fever ends) of the person with suspected or confirmed influenza
• If more than 4 days have elapsed since the last infectious contact

• See Management of COPD During COVID-19
• See Addressing therapeutic questions to help Canadian physicians optimize asthma management for their patients during the COVID-19 pandemic (CTS)
• Consider referring patients who smoke to STOP on the Net (CAMH), an online program that offers free nicotine replacement therapy​​ (NRT) and other supports and resources to help people quit or reduce smoking.

• Consider a mass mail or email to remind all patients to seek care if needed, and describe your clinic’s new processes, masking policy, safety protocols for in-person visits and virtual care options.
• In most cases, in-person care can be provided safely and should be prioritized. However, virtual care can be utilized as needed to ensure care is still provided.
• Consider prioritizing the following patient populations:
  • Those at risk for developing or worsening mental health or addiction.
  • Those at risk of overdose. See CEP’s Opioid Overdose Risk and Prevention resource.
  • Those who are not up to date for immunizations (children and adults). See Ontario’s Immunization schedule.
  • Those with mobility issues.
  • Those with poorly-controlled chronic conditions.
  • Those with a scheduled procedure, test, or surgery that was postponed due to COVID-19.
  • Those who have missed or are due for a cancer screening. See Ontario Health (Cancer Care Ontario)’s COVID-19 Cancer Screening Tip Sheets and Screening Resources for Healthcare Providers and note that, as of July 1, Nurse Practitioners will be able to order CT and MRI scans.
  • Those recently discharged from hospital.

• • Refer to the above information for a list of patient populations to consider prioritizing
• When running reports in your EMR to identify patients, consider the following:
  • Structured information (birthdate, sex) is typically the most easily queried.
  • You can use your EMR to search for specific health conditions, immunization history, last visit date and other information about your practice. You can generate a report to pull the data from the EMR.
  • Consider creating searches using the patient’s CPP (e.g. Problems/Diagnosis list).
  • Reports particularly useful at this time would include:
    • Specific chronic conditions
    • A combination of last date seen OR last note made OR last date billed within your chosen date range (last 6 months, last 9 months, etc)
    • Preventative Care Queries/Preventative Care Summary Reports for active patients in need of cancer screening
• The eHealth Centre of Excellence offers free EMR coaching, and a collection of automated solutions that can help clean up, standardize and search through data in your EMR.
• If you are unsure of how to use your EMR to support proactive panel management, there are free OntarioMD resources to help you:
  • i4C Advisory Service: Free service providing hands-on support from OMD Practice Advisors and Peer Leaders to create an enhancement plan reflecting individual practice priorities.
  • Peer Leaders: Peer Leaders work one-on-one to help providers get more value from their certified EMR.
  • EMR Progress Assessment Tool: Free, evidence-based, online self-assessment for providers to assess their EMR use and make improvements to enhance patient care. The EPA investigates key functional areas: Practice management, information management, and diagnosis/treatment support.

• Some patients might not be able and/or comfortable accessing resources in the community for a variety of reasons (e.g., isolation, fear of infection, mental health concerns, financial insecurity, health conditions, complex social needs, etc.)
• See Social Prescribing: a resource for health professionals for practical tips on how to incorporate social prescribing into your practice.
• For support and resources on answering patient questions about COVID-19 vaccines, view Ensuring Patient Confidence in Vaccines
• See Local services for links to a variety of supports and resources by region.
• See Poverty: A Clinical Tool for Primary Care Providers for guidance on screening and supporting patients living in poverty.

Step 1

Presume any household members with COVID-19 symptoms have COVID-19.

All household members should isolate (stay home) UNLESS any of the following apply**:

• They tested positive for COVID-19 within the prior 90 days
• Are 18+ and boosted
• Are under 18 years old and are fully vaccinated.

Healthcare workers should follow any work self-isolation policies.

Step 2

Obtain COVID-19 testing for the symptomatic person:

• Serial rapid antigen test (RAT): 2 tests, taken 24 – 28 hours apart; OR
• Polymerase chain reaction (PCR) test (household members of HCWs working in highest-risk settings are eligible for PCR testing as of Jan 13/22)

Step 3

If COVID-19 testing is NEGATIVE, the HCW can discontinue isolation.

If COVID-19 testing is POSITIVE, asymptomatic HCWs who have not had a positive COVID-19 test in the last 90 days should:

• Obtain PCR testing per local Public Health guidance
• Isolate (stay home) while the symptomatic person is isolating. If the HCW is immunocompromised, they will need to isolate for 10 days (20 days if they are severely immunocompromised
• Not work for 10 days from their last exposure to the symptomatic person during their infectious period (from 48 hours prior to symptom onset until the end of their isolation period) unless they can complete RAT tests (see below).
• Follow guidance for COVID-19 cases if symptoms develop or they test positive for COVID-19

Healthcare workers who are following workplace self-isolation should:

• Stay home for the isolation period and only leave home for essential work;
• Wear recommended personal protective equipment including a fit-tested N95 mask while at work
• Stay 2 meters away from others at work except to provide direct patient care;
• Take breaks alone and wash their hands often
• Ideally, work at one facility only;
• Follow testing requirements.

Under routine operations asymptomatic close contacts that work in highest-risk settings may return to work:

1. Following a negative molecular test (e.g., PCR, rapid molecular) collected on/after day 5 from last exposure
   OR
2. Following a negative molecular test (e.g., PCR or rapid molecular) collected before day 5 after last exposure AND performing daily rapid antigen tests for 10 days after last exposure or until a second negative molecular test is collected on/after day 5 after last exposure
   • Asymptomatic close contacts who are returning after a negative molecular test collected before day 5 after last exposure are recommended to follow the Workplace Measures below for reducing risk of exposure.

Please see Management of Cases and Contacts of COVID-19 in Ontario (November 30, 2022) for guidance during critical staff shortage

* highest risk settings include: hospitals including complex continuing care facilities and paramedic services; and congregate living settings, including long-term care homes, retirement homes, First Nation elder care lodges, group homes, shelters, hospices, and correctional facilities.
**Wear a well-fitted mask in public, physical distance and maintain other public health measures for 10 days following last exposure if leaving home. HCW should NOT visit or attend work in any highest risk settings and not visit individuals who may be at higher risk of illness (i.e., seniors or immunocompromised) for 10 days after your last exposure.

Healthcare workers (HCWs) with a positive COVID-19 rapid antigen test (RAT) or polymerase chain reaction (PCR) test must isolate (stay home).

• HCWs who have had at least 2 COVID-19 vaccine doses must isolate for 5 days from the day of the positive test (day of positive test is Day 0).
• HCWs who have NOT had at least 2 COVID-19 vaccine doses AND healthcare workers who are immunocompromised must isolate for 10 days from symptom onset (day of symptom onset is Day 0).
• If symptoms develop, follow isolation guidance for symptomatic HCWs
• HCWs can exit isolation once their isolation period is complete EVEN IF other household members are still isolating.

Healthcare workers who are close contacts who have previously tested positive for COVID-19 in the last 90 days (based on positive rapid antigen test or molecular test results) can attend work in the highest-risk setting, as long as they are currently asymptomatic. These individuals are advised to self-monitor for symptoms for 10 days after last exposure.

For early RTW:
Under routine operations, asymptomatic close contacts that work in highestrisk settings may participate in testing for early return to work:

• Following a negative molecular test (e.g., PCR, rapid molecular) collected on/after day 5 after last exposure
  OR
• Following a negative molecular test (e.g., PCR or rapid molecular) prior to first shift (if collected before day 5) AND perform daily rapid antigen testing for 10 days after last exposure or until a second negative molecular test is collected on/after day 5 from last
  exposure

Please see Management of Cases and Contacts of COVID-19 in Ontario (November 30, 2022) for guidance during critical staff shortage

** highest risk settings include: hospitals including complex continuing care facilities and paramedic services; and congregate living settings, including long-term care homes, retirement homes, First Nation elder care lodges, group homes, shelters, hospices, correctional facilities and home and community care settings.

Step 1

Healthcare workers (HCWs) with COVID-19 symptoms should presume they have COVID-19 and isolate (stay home) while awaiting test results.

Step 2

Where possible, the HCW should obtain COVID-19 testing:

• Serial rapid antigen test (RAT): 2 tests, taken 24 – 28 hours apart; OR
• Polymerase chain reaction (PCR) test

Step 3

If COVID-19 testing is NEGATIVE, the HCW can discontinue isolation when they have been fever-free for 24 hours AND symptoms have been improving for at least 24 hours (48 hours for gastrointestinal symptoms).

If COVID-19 testing is NOT AVAILABLE or POSITIVE, the HCW must isolate (stay home):

• HCWs who have had at least 2 COVID-19 vaccine doses OR who have had a COVID-19 infection within 90 days must isolate for at least 5 days from symptom onset (day of symptom onset is Day 0).
  Isolation can end after 5 days IF they have not had a fever in 24 hours AND symptoms have been improving for at least 24 hours (48 hours for gastrointestinal symptoms).
• HCWs who have NOT had at least 2 COVID-19 vaccine doses AND healthcare workers with immunocompromise must isolate for at least 10 days from symptom onset (day of symptom onset is Day 0). HCWs with severe immunocompromise must isolate for at least 20 days from symptom onset (day of symptom onset is Day 0).
  Isolation can end after Day 10 (or Day 20) IF they have not had a fever in 24 hours AND symptoms have been improving for at least 24 hours (48 hours for gastrointestinal symptoms).
• HCWs can exit isolation once their isolation period is complete EVEN IF other household members are still isolating.

HCWs in highest risk settings* should follow workplace guidance to return-to-work (RTW). In general, HCWs who are not immunocompromised can RTW:

For routine operations, COVID-19 positive cases that work in highest-risk settings may return to work:

1. 10 days after symptom onset or date of specimen collection (whichever is earlier)
   AND
2. Provided they have no fever and other symptoms have been improving for 24 hours (or 48 hours if vomiting/diarrhea). 

Note: Testing for clearance is generally not recommended.

Please see Management of Cases and Contacts of COVID-19 in Ontario November 30, 2022) for guidance during critical staff shortage

* highest risk settings include: hospitals including complex continuing care facilities and paramedic services; and congregate living settings, including long-term care homes, retirement homes, First Nation elder care lodges, group homes, shelters, hospices, correctional facilities and home and community care settings.

No (CPSO, 2021). Even in the absence of a negative test result or vaccination, in-person care can be provided safely by taking appropriate precautions (screening patients and using necessary PPE). While you can encourage eligible patients to get vaccinated, patients cannot be denied access to necessary in-person care based solely on their vaccination status.

The right balance between providing in-person and virtual will vary by physician practice. Every practice is unique, and the decision about the care provided will require judgment on the part of the physician to determine how best to serve their patients’ needs. The pressures that existed at a different stage in the pandemic (e.g., lack of PPE, high number of cases) have now diminished. When taking appropriate precautions, in-person visits can now be provided safely and appropriately, and may be in your patient’s best interest in some instances.

Your patient’s best interests will include taking into consideration the type of visit they would prefer. In this situation an in-person visit should be offered as long as you are able. To ensure that the appropriate safety precautions are in place, see the PPE section for more information.

• Maintain cool environment.
• Topical moisturizers and petroleum jelly or baby napkin cream (only if use does not interfere with proper fit).
• Use alternate mask type if one type is particularly irritating.
• Take breaks from respirator use, with careful attention used when donning and doffing (especially when the respirator is being re-used).
• Caps, headbands or fabric with buttons for straps of masks may reduce ear irritation but may increase pressure on front of face. This should only be done if it does not interfere with the proper fit of the PPE. These items must be integrated into proper donning/ doffing cycle and reprocessed or laundered appropriately with other PPE.

• Use full face-shield.
• Change to shorter, rotating shifts.
• Lubricants to reduce friction between skin and goggles.
• Avoid tight equipment.
• Wet compression for severe skin indentations.
• Avoid irritating agents when washing face.

• For overheating: Avoid plastic gowns, maintain hydration, use shorter, rotating shifts and over-tight equipment.
• For irritation: wear a barrier between body and PPE (unless overheating is issue) and avoid over-tight equipment.

• Ensure hands are dry before donning gloves.
• Choose non-irritating gloves (avoid latex).
• Choose correct glove size.
• Moisturize often, but avoid moisturizing immediately prior to donning gloves. Moisturizer is not sterile and can interfere with glove integrity.

• Avoid hot water.
• Rinse soap well.
• Use hypoallergenic products (including at home).
• Pat hands dry with paper towel instead of rubbing.
• Moisturize often using a fragrance-free lotion or cream that contains humectants, fats and oils at least twice a day for prevention, and as often as feasible (including at work) for treatment.
• Barrier cream efficacy unclear, such products are expensive, not removed by handwashing, and may = glove breakdown.
• Avoid use of hand sanitizer immediately before or after handwashing.
• Hand sanitizer is less likely to cause initial skin irritation than soap and water, but is more likely to cause acute pain once irritation occurs.
• Ensure hands are dry before donning gloves.