Respiratory Illness Tools and Resources for Doctors

Access to COVID-19 Testing

Rapid Antigen Testing:

• Health care providers can order and provide rapid antigen tests (RATs) to patients keep on hand to make testing and treatment more accessible. See Ministry of Health Memo (PDF) for more details.
• Order RATs through existing channels. If not yet enrolled in Provincial Antigen Testing Program (PASP), enroll through the Ontario Together Portal (external website), and order via the PPE Supply Portal (external website).
• Individuals can access RATs at Public Health Units and participating pharmacies (external website).

PCR Testing:

• Available for patients at high risk of severe illness at participating community labs, pharmacies and at the 30 remaining clinical assessment centres.
• Individuals can check to see if they are eligible (external website) and use the PCR testing locator tool (external website) to find their nearest location or use the Ministry of Health’s online screening tool (external website) to determine if they are eligible for PCR testing and antiviral treatment.
• The OMA has a guide for community-based practices offering PCR testing. (PDF)

Rapid Molecular Testing:

• 134 active ID NOW sites offering testing in Ontario (external website) with 86 sites in the North region offering access to molecular testing in areas without easy access to lab-based testing.

Consider participating in the Public Health Ontario’s Sentinel Practitioner Surveillance Network (SPSN) to help monitor respiratory pathogen activity in your community.

Antivirals

Patients at higher risk of severe illness from COVID-19 and influenza should be seen as soon as possible to benefit from antiviral treatments. Engage with high-risk patients before they get sick during regular appointments to ensure they know what to do to receive the appropriate therapeutic within the treatment window if they get sick.

Make every effort to identify and connect with your higher-risk patient within 24 hours of patient seeking assessment for respiratory illness symptoms.

OCFP’s Screening for Respiratory Illness Symptoms (PDF) can help front office staff identify high-risk patients with respiratory illness symptoms and prioritize appointments to ensure timely access to antiviral treatments for influenza and COVID-19.

Influenza Antivirals

When influenza is circulating in the community, oseltamivir or zanamivir therapy is recommended for children and adults with influenza-like illnesses who are at higher risk of severe illness, have progressive symptoms, or who are hospitalized.

Antivirals for flu work best when initiated as soon as possible and ideally within 48 hours of symptom onset, but treatment initiation beyond the 48-hour window may be considered. Lab confirmation of influenza is not required to start treatment.

Public Health Ontario’s resource Antiviral Medications for Seasonal Influenza (December 2022) summarizes AMMI recommendations. An updated version is planned for fall 2023.

COVID-19 Antivirals

• Patients must be at high risk for hospitalization or death due to COVID-19. However, eligibility is ultimately based on prescriber’s clinical discretion and risk-benefit assessment.
• A COVID-19 diagnosis is required prior to initiating antiviral therapy (i.e., positive PCR, rapid molecular or rapid antigen test).
• COVID-19 antivirals are free to anyone with a prescription.

Paxlovid

• Preferred first-line therapy.
• Must be initiated within five days of symptom onset.
• Approved for high-risk adults.
• Can be prescribed by physician, nurse practitioner or participating pharmacist.
• Interacts with many commonly used medications and natural health products. Requires careful risk assessment
  and collaboration with pharmacist and/or specialists (e.g., transplant, oncology) to assess for contraindications

Remdesivir

• Indicated where Paxlovid is contraindicated (e.g., drug-drug interaction that cannot be safely managed, medical contraindication) or when patients are beyond the treatment window for Paxlovid (> 5 days).
• Must be initiated within seven days of symptom onset.
• Approved for high-risk adults and pediatric patients > 40 kg.
• Only available as an IV formulation which requires nursing support to administer on three consecutive days.
• Remdesivir is available through Home and Community Care Support Services (HCCSS). Find referral forms here.
  • HCCSS care coordinators will follow up with your patient.
  • Patients will receive IV therapy through infusions at a community nursing clinic; at-home service may be provided if required.

Ontario Health resources on COVID-19 treatments, including newly published guidance on:

• Access to antiviral treatments for COVID-19 in the community (September 15, 2023)
• Ontario Health Recommendations for Outpatient Use of Intravenous Remdesivir in Adults (September 15, 2023)

Centre for Effective Practice has guidance on the outpatient management of patients with COVID-19.

Identifying High-Risk Patients

Ontario Health guidance defines high-risk patients as follows:

• Adults ≥ 60 years of age.
• Adults who are immunocompromised, regardless of age, vaccine status or prior infections.
• Unvaccinated or not up-to-date on vaccinations.
• Adults with one or more high-risk medical conditions.
• Individuals who are at a higher risk of severe illness from COVID-19 based on social determinants of health including:
  • Indigenous people, Black people, other members of racialized communities, people who are underhoused, individuals with intellectual, developmental, or cognitive disability, people who use substances regularly and/or live with mental health conditions.

Download the PDF

OCFP’s IPAC resource (October, 2023) contains more information on office flow, masking, PPE and more.

Screening

• Screen all patients for symptoms of respiratory illness.
• Screen patients passively with signage.
• Screen actively with questions on the phone or web-based booking system (see OCFP tool Screening for Respiratory Illness
• Symptoms developed to help your appointment booking staff).
• Screen again when patients present to the clinic.

Masking

If you are not requiring universal masking, ensure patients with respiratory symptoms and their accompanying caregivers are required to wear masks. When rates of respiratory illness increase, return to a universal masking policy where they have been stopped.

See here for OCFP’s printable “Reminder to wear mask” signs.

Scheduling and Clinic Flow

• Where possible, schedule symptomatic patients separately from other clinic patients—at the beginning or the end of the day.
• Separate patients who have respiratory symptoms from others in your space.
• Do not cohort patients who have respiratory symptoms together unless they live in the same household.
• Continue to facilitate physical distancing in patient areas as much as possible.
• Stagger in-person and virtual appointments to enable room cleaning and to minimize time patients spend in the waiting room/ shared spaces.
• Reduce non-essential items in patient areas.

PPE and RATs

• Assess inventory of PPE resources to support staffing needs: masks, gloves and hand sanitizer.
• Consider stocking rapid antigen tests (RATs) in your clinic to allow on-site testing.
• Order RATs through existing channels. If not yet enrolled in Provincial Antigen Testing Program (PASP), enroll through the Ontario Together Portal, and order via the PPE Supply Portal.
• Individuals can access RATs at Public Health Units and participating pharmacies.

Additional Resources

OMA has updated their guide to Safely Providing In-Person Care (member login required).

Centre for Effective Practice resource Primary Care Operations in the COVID-19 Context.

Download the PDF

Inform and educate patients about vaccines as a safe and effective strategy to reduce the risk of serious illness from COVID-19, influenza, pertussis and pneumococcus, particularly for people older than 60, pregnant people, children and those with health conditions that put them at greater risk of serious illness.

See OCFP’s resource on Physician-Patient Discussions for more information on talking to patients about preventing serious respiratory illnesses this season.

You can refer vaccine-hesitant patients to VAXFacts+ for a phone appointment. Patients can reside anywhere in Ontario and no OHIP card is required.

COVID-19 Vaccines

As of September 12, 2023, Health Canada has authorized the new Moderna Spikevax Monovalent COVID-19 Vaccine targeting the Omicron XBB.1.5 subvariant for people six months of age and older.

Authorized for those not previously vaccinated (formerly referred to as the primary series) and those previously vaccinated (formerly referred to as the booster dose), including:

• Twelve years and older
• Five-11 years
• Six months to four years (If not previously vaccinated, Spikevax XBB.1.5 should be administered as a two-dose regimen)

This is the first time an additional dose of the COVID-19 vaccine has been authorized for children six months to less than five years of age who have been previously vaccinated with a primary series.

COVID-19 Vaccine Resources

• Moderna Spikevax Monovalent XBB.1.5 Dosing, Administration & Storage and Product Monograph
• NACI Addendum to the guidance on the use of COVID-19 vaccines in the fall of 2023 (PDF, September 12, 2023).
• NACI Guidance on the use of COVID-19 vaccines in the fall of 2023 (July 11, 2023).
• Ministry of Health COVID-19 Vaccine Guidance (PDF, July 7, 2023).
• Ministry of Health Vaccine-Relevant Information and Planning Resources.
• Centre for Effective Practice resource COVID-19 in 2023: Care and Operations Guidance.

OMA Resources to support offering COVID-19 vaccines in your practice (member login required)

• Checklist and practical tips for providing COVID-19 vaccines through your practice.
• Deciding whether to provide the COVID-19 vaccine in your practice: Considerations for workload, financial feasibility, capacity and logistics.
• COVID-19 Vaccine Reference Tool to help determine appropriate doses and intervals for patients based on age and immune status.
• Overview of the COVID-19 vaccine billing codes.
• Pathways to COVID-19 vaccines for patients with allergies.

Influenza Vaccines

NACI recommends offering influenza vaccines to everyone six months and older who does not have contraindications. Influenza vaccination is particularly important for people at higher risk of influenza-related complications or hospitalization, people capable of transmitting influenza to those at higher risk of severe illness, people who provide essential community services, and people who are in direct contact with poultry infected with avian influenza during culling operations.

• Children six months to nine years of age who have not received any prior influenza vaccine doses should receive two doses of vaccine, administered at least four weeks apart.
• Everyone six months and older who has received one or more previous doses of influenza vaccine should receive one dose of vaccine.

Influenza Vaccine Resources

• NACI Statement on seasonal influenza vaccine for 2023-2024 (last updated August 24, 2023).
• OMA’s Influenza Quick Reference Guide summarizes available influenza vaccines, age-specific information, dosing and other key considerations for administering influenza vaccines in your clinic (member login required).

Co-administering Vaccines

COVID-19, non-live influenza vaccines, pneumococcal vaccines, and respiratory syncytial virus vaccines can safely be co-administered. However, the MOH guidance for the Imvamune vaccine for mpox recommends waiting 4-weeks to administer a COVID-19 vaccine or any live vaccines, and 2 weeks to administer other non-live vaccines.

Co-administration of vaccines reduces barriers to access for patients and makes more efficient use of health care provider time and resources.

Other vaccines you may want to offer to higher-risk patients

RSV Vaccine

Health Canada has authorized the RSV vaccine, Arexvy for those 60 years and older. The Ministry of Health recently announced that it will be publicly funded for those living in long-term care homes, Elder Care Lodges, and some retirement home residents. More information on eligibility and availability to follow in the coming weeks.

• Respiratory syncytial virus (RSV): Canadian Immunization Guide (last updated September 8, 2023).

Pneumococcal Vaccine

Recommendations: New Health Canada Authorized Pneumococcal Conjugate Vaccines (Public Health Ontario, September 1, 2023).

Pertussis (Tdap) Vaccine

A reminder of the expanded public funding to offer a routine Tdap dose in every pregnancy, regardless of immunization history.

• Ministry of Health Tdap Vaccine FAQs for Immunizers.
• NACI Update on immunization in pregnancy with Tdap vaccine.

Download the PDF

Considerations for Infectious Respiratory Diseases for Community Practices

As we enter the fall and winter respiratory illness season, we are seeing COVID-19 cases and hospitalizations starting to increase and other respiratory illnesses, including influenza and RSV, are expected to increase in the coming months. See OCFP’s respiratory illness season tools and resources page for up-to-date information to support your practice during this time.

As of September 14, 2023, health care providers participating in the Provincial Antigen Testing Program can order RATs to distribute to patients as well as staff. If not yet enrolled, apply through the Ontario Together Portal, and order via the PPE Supply Portal.

Personal protective equipment (PPE) continues to be available through the Provincial PPE Supply Portal. New users can register here to order.

See below for more information on measures for infection prevention and control against COVID-19 and other respiratory viruses, including screening, masking, PPE, physical distancing, cleaning, and ventilation.

Other resources you may find useful:

•PHO Interim Infection Prevention and Control Measures Based on Respiratory Virus Transmission Risk in Health Care Settings
• For more on these guidelines watch the May 26, 2023 “Changing the Way We Work (COVID-19) Community of Practice” recording (beginning at 6:15).
• PHO IPAC Checklist (July 2019)
• OMA guide on IPAC and safely providing in-person care
(member log-in required).

Masking

Masking is not required at this time but still recommended in clinical settings this fall and winter.

In all practices, mask wearing is mandatory for patients with signs and symptoms of infectious respiratory diseases.

As cough and cold season approaches, many Ontario hospitals have announced that they are bringing back mask requirements in patient-care areas. Masking continues to be recommended in any community-based practice with high-risk/ vulnerable patients to protect both those providing and accessing care.

If you are not currently requiring universal masking, consider using a patient-centred approach. If a patient enters your clinic wearing a mask, consider reciprocal mask-wearing to respect and acknowledge their concerns and communicate your solidarity with their precautions.

PHO recommends masking for direct patient care during high-risk periods. Ontario’s Respiratory Virus Tool (updated every Friday) can provide you with current information on respiratory virus activity in Ontario and by Public Health Unit. Consider your own and other clinic staff’s personal risk tolerance in your risk assessment.

Regularly review your clinic’s masking requirements when respiratory illnesses are increasing in your community – consider returning to a universal masking policy in clinics if you are not currently masking.

The Ministry of Health currently recommends to the public: “Ontarians may consider wearing a tight-fitting, well-constructed mask in indoor public settings, especially anyone at higher risk of severe infection. Setting-specific masking policies should be followed.”

If a patient will not or cannot adhere to your clinic’s masking requirement: See
CPSO’s COVID-19 FAQs for Physicians “What if a patient refuses to wear a mask” for options on how to proceed.

Resources:

Download our clinic sign to remind patients to wear a mask. (English / French)
Download our clinic sign to remind patients that abusive behaviour is unacceptable.

Screening

Note: A negative COVID-19 test and/or proof of vaccination should not be required for an in-person patient visit.

Active Screening: Screen patients for signs and symptoms of infectious respiratory diseases to guide care decisions as well as in-office PPE and IPAC measures. Active screening is part of best practices regardless of transmission risk.

Passive Screening: Use signage at office /clinic and building entrance and
ask staff, patients, and visitors to self-identify, if ill, to augment active screening.

Staff Screening: Ask all staff to self-monitor for signs and symptoms of infectious respiratory diseases.

Prioritize Appointments for High Risk Patients: You can use this OCFP tool to help front office staff screen patients with respiratory symptoms to ensure timely access to influenza and COVID-19 antiviral treatments for individuals at risk of severe complications.

PPE

Direct care/within 2 meters of patients with signs and symptoms of infectious respiratory diseases:

• Require symptomatic patient & any accompanying caregiver to wear masks.
• Respiratory etiquette.
• Hand hygiene: ensure ABHR is available at point of care and not expired.
• Wear a mask (e.g., fit-tested, seal-checked N95 respirator, a non-fit-tested N95 or equivalent, or a well-fitting medical mask).
• Full PPE (i.e., + eye protection, gloves, gown), based on your discretion/ a point-of-care risk assessment.
• Clean & disinfect (refer to the ‘Cleaning’ section).

Care of patients with no signs or symptoms of infectious respiratory diseases:

• Follow your clinic’s masking policy. To determine if additional PPE is required, use your discretion or PHO’s point-of-care risk assessment.

Office Flow

Tip: Consider developing a process (e.g., colour coding in your schedule) that highlights and categorizes patients with signs and symptoms of infectious respiratory diseases to triage patients to determine who needs to go into an examination room quickly.

• Minimize time patients spend in the waiting room/shared spaces and reduce non-essential items in patient areas.
• Where possible, schedule symptomatic patients separately at the beginning or the end of the day.
• Seat patients with signs and symptoms of infectious respiratory diseases apart from other patients and require them, and any accompanying caregivers, to wear a medical mask. Triage these patients into a single room as soon as possible.

Cleaning

Medical equipment that only comes into contact with the patient’s intact skin and is used between patients requires cleaning and low-level disinfection after each use (e.g., armrests on chairs; examination table; BP cuff).

Ensure there is a process in place for cleaning after each patient interaction.

Ensure staff are trained in how to clean and how to use the product (contact time, application), using a hospital-grade low-level disinfectant (e.g., has a drug identification number).

Ventilation

Ensure ventilation system is functioning properly and optimized. If available, request report from the building owner/landlord.

Consider an air cleaner with a HEPA (high-efficiency particulate air) filter if HVAC is very poor or non-existent, or there is no outdoor air exchange. Select a portable air cleaner with clean air delivery rate (CADR) large enough for the size of the room or area.

Resources:
PHO HVAC guide (not specific to health care)
PHO FAQs on portable air cleaners
CDC’s strategies and tools for improving building ventilation in the context of virus transmission.

Download the PDF

The OFCP has created Fall 2023 Respiratory Illness Season patient-directed resources on various topics, that you can share via email, clinic signage and/or on your practice’s website.

Recommend Influenza and COVID-19 Vaccination

• Inform and educate patients about vaccines as a safe and effective strategy to reduce the risk of serious illness from COVID-19, influenza, pertussis and pneumococcus, particularly for people older than 60 and those with health conditions that put them at greater risk of severe illness.
• Remind pregnant people and people who have recently given birth:
  • Influenza and COVID-19 are more severe in pregnancy and can cause pregnancy complications such as pre-term birth.
  • Reassure that vaccines are safe and effective in pregnancy and antiviral therapies should be considered if they get sick.
  • Additional benefit of antibodies from flu and COVID-19 vaccines (as well as the pertussis vaccination) are passed to the fetus and found in breastmilk which helps to protect their baby.
• Remind parents that it is important for young children to receive vaccinations for flu, COVID-19 and pertussis and especially for children under five who are at greatest risk for severe outcomes and hospitalization.
• Where capacity allows, offer vaccination in your clinic and/ or encourage patients to access vaccines from your local public health unit or participating pharmacies.
• Reassure patients, parents and caregivers that co-administration of vaccines is safe.
• Refer vaccine-hesitant patients to VAXFacts+ (external website), available to anyone in Ontario.

Identify and Engage Proactively with Your Higher-risk Patients

Aside from the specific health conditions that put people at greater risk of severe illness from flu or COVID-19, when discussing vaccines and potential antiviral treatments, it’s essential to consider other patients in your practice who may also face serious illness if they get sick.

Consider Social Determinants of Health

People from racialized groups; people living in low-income neighbourhoods; Indigenous people living on reserves; and people with overcrowded or unstable housing are more likely to experience severe illness from COVID-19 and influenza (flu). Other social determinants of health— food insecurity, precarious employment, lack of access to paid sick time to care for self or keep sick children home, disability, mental health conditions and substance use—can impact people’s ability to care for themselves putting them at greater risk of serious illness from flu and COVID-19. Include these groups in your work to increase awareness, vaccine uptake and early presentation for consideration of antivirals.

Ensure Higher-Risk Patients are Aware of Pathways to Access Testing and Antivirals if They Get Sick

• Communicate to patients who are at higher risk the importance of reaching out early with respiratory illness.
• Discuss treatment pathways during regular appointments, and highlight alternative ways of accessing therapy
  (e.g., pharmacist prescribing).
• Communicate this information to patients at higher risk of severe illness via by phone, email, clinic signage and/or on your practice’s website.

Consider referring COVID-19 positive patients who are 50+ years or 18-49 years, with one or more chronic condition(s), to the CanTreatCOVID study. See here for more information and FAQs.

This Canada-wide study aims to identify effective, affordable and evidence-based medications for COVID-19 that would reduce emergency department visits and hospital stays and help people feel better faster. The long-term goal of the study is to find medications that prevent long COVID. You can let patients know that they will be closely monitored by a healthcare team, and receive personalized care and attention, as well as access to specialized resources and support.

Healthcare providers can receive $40 for referring potentially eligible participants and patients can receive up to $120 while in the study.

To refer your patients (patients may self-refer):​

• Self-screening form: https://cantreatcovid.org/​
• Phone: 1-888-888-3308 (Monday – Friday, 8 am to 6 pm ET)​
• Email: info@CanTreatCOVID.org​
• Website: CanTreatCOVID.org/contact

High-risk patients should be encouraged to “have a plan” if they get sick:

• Keep rapid antigen tests (RATs) on-hand or know their closest PCR testing location (external website).
• Use the provincial screening tool (external website) to access COVID-19 testing and antivirals.
• Understand the importance of accessing care as soon as possible after symptom onset.
• Have a medication list ready with up-to-date prescriptions and over-the-counter medications/supplements listed.

Implement strategies to support timely access to COVID-19 and influenza antiviral treatments for patients at higher risk of serious illness.

Use OCFP’s tool (PDF) in your clinic to prioritize appointments for high-risk patients to allow timely access to antivirals.

Help Patients Manage Their Symptoms at Home

• Reassure patients that most people with viral infections should self-isolate and manage symptoms expectantly. Share trusted resources:
  • OCFP’s Family Doctor Tips for Teens and Adults with Colds, the Flu or COVID-19 (PDF)
  • OCFP’s Family Doctor Tips on Caring for Children with Respiratory Symptoms
  • Ministry of Health resources on protecting yourself and your loved ones from respiratory viruses and what to do if you get sick. (External website)
• Educate patients that COVID-19 and flu antivirals are only recommended for those with risk factors for severe illness and hospitalization.
• Remind patients that if they are higher risk and do get sick—they should not delay getting medical attention so that they can access potential treatments.
• Remind patients that most people are not eligible for PCR tests.
• If patients are using RATs (external website) remind them to collect a good specimen from the buccal mucosa, pharynx, and nares, and to conduct serial testing for the most accurate result.
• Advise patients on reducing the risk of transmission at home and community:
  • Remind patients who have a respiratory illness to stay at home until they have no fever and symptoms are improving for at least 24 hours (or 48 hours with vomiting and/or diarrhea).
  • Use high-quality and well-fitting masks, and practice good hand and respiratory hygiene,
  • Remind patients they can optimize ventilation in the home by running fans including bathroom fans, open windows, using air purifiers (e.g., homemade Corsi-Rosenthal box, HEPA filters).
• Ensure patients are aware of your availability and after-hours services and when to call for an urgent appointment; when to contact Health 811; or when to go the emergency department.

Respiratory Illness Physician-Patient Discussions (PDF)