COVID-19: Weekly Update Archive
An archive of previous entries in the Weekly Update series on AccessMedicine COVID-19 Central
April 21st through May 3rd
Welcome to the McGraw-Hill COVID-19 channel. In this bi-weekly update we have information about the safety of the mRNA vaccines in pregnancy, new treatment guidelines from the NIH and information on the impact of COVID-19 on other chronic illnesses. Finally, we have information on the resumption of the Johnson & Johnson/Janssen vaccine in the United States, a link to the new CDC mask recommendations for those fully vaccinated and a link to the CDC safety guidelines for summer camps.
The NIH has released new guidelines for the treatment of COVID-19. Among the changes are recommendations about use of colchicine, fluvoxamine, monoclonal antibodies, convalescent plasma, and other drugs
Some of the changes include:
- Colchicine: There is insufficient evidence to recommend for or against colchicine in outpatients. The recommendation is against the use of colchicine for inpatients except in the setting of a trial.
- Fluvoxamine: There is insufficient data to recommend for or against fluvoxamine.
- Monoclonal antibodies. Single agent monoclonal antibodies are no longer recommended due to the resistance of several SARS-CoV-2 strains. The combinations of bamlanivimab 700 mg plus etesevimab 1,400 mg or casirivimab 1,200 mg plus imdevimab 1,200 mg are recommended for high risk outpatients (the Emergency Use Authorizations (EUAs) defining “high risk” can be found here for bamlanivimab plus etesevimab and here for casirivimab plus imdevimab).
- Convalescent plasma: Low titer COVID-19 convalescent plasma is no longer authorized for use. Routine use of high titer convalescent plasma is recommended against except in a clinical trial. For those who have impaired immunity, there is insufficient evidence to recommend for or against high-titer convalescent plasma. More information can be found here.
- Tocilizumab is now recommended for use with dexamethasone in some cases. More information can be found here.
- Outpatient treatment of COVID-19. There is a new section on the diagnosis and management of outpatient COVID-19. Outpatient treatment recommendations can be found here.
- Therapeutic Management of Adults with COVID-19. The executive summary including a summary table can be found here.
These recommendations cannot be easily summarized in a couple of paragraphs and should be reviewed by those taking care of inpatients and outpatients with COVID-19. A link to the updated guidelines can be found here.
- NIH COVID-19 Treatment Guidelines: What’s New in the Guidelines Available at https://www.covid19treatmentguidelines.nih.gov/whats-new/ Accessed 21 April 2021.
The mRNA vaccines are safe in pregnancy. In the previous week’s post, we noted that SARS-CoV-2 mRNA vaccines generate a robust antibody response during pregnancy. We now have additional data on the safety of these vaccines during pregnancy. This study looked at vaccine safety registries (v-safe pregnancy registry, Vaccine Adverse Event Reporting System (VAERS)) to determine the safety of mRNA vaccines during pregnancy1. 35,691 pregnant individuals were identified between the ages of 16-54.
Injection site reactions were identified more frequently in pregnant patients whereas most systemic reactions, except for nausea and vomiting, were reported more frequently in non-pregnant patients.
3958 v-safe patients were followed up by phone of whom 827 had a completed pregnancy. Rates of spontaneous abortion (<20 weeks), stillbirth ≥ 20 weeks, preterm birth, congenital anomalies, etc. were comparable to the baselines published in the literature (although the groups were not matched for age, “race”, ethnicity, etc.).
This study is reassuring. The rate of adverse pregnancy outcomes after SARS-CoV-2 mRNA vaccination is comparable to baseline rates. Given the known adverse impact of COVID-19 on pregnancy, we should encourage vaccination.
- Shimabukuro TT, Kim SY, Myers TR, et al. Preliminary Findings of mRNA Covid-19 Vaccine Safety in Pregnant Persons DOI: 10.1056/NEJMoa2104983 https://www.nejm.org/doi/full/10.1056/NEJMoa2104983 accessed 1 May 2021
- Villar J, Ariff S, Gunier RB, et al. Maternal and Neonatal Morbidity and Mortality Among Pregnant Women With and Without COVID-19 Infection: The INTERCOVID Multinational Cohort Study. JAMA Pediatr. Published online April 22, 2021. doi:10.1001/jamapediatrics.2021.1050
COVID-19 may have adverse effects on chronic health conditions. Post-acute COVID-19 syndrome (PACS/”Long hauler syndrome”) is well described: fatigue, “brain fog”, respiratory complaints, myalgias, anosmia, etc. This study looks at the effects of COVID-19 infection on long-term mortality and chronic illnesses such a cardiac disease and diabetes, etc. This is a cohort study of 73,435 patients in the Veteran’s Health Administration (VA) who were at least 30 days out after a COVID-19 diagnosis. None of the patients had been hospitalized. They looked at the risk of death at 30 days and 6 months, the risk of cardiovascular conditions, metabolic disorders and more. The control group included 5,000,000 unhospitalized VA patients who were never diagnosed with COVID-19.
The hazard ratio for death greater than 30 days from the diagnosis of COVID-19 was HR 1.59 (95%CI 1.46-1.73). At 6 months, excess deaths were estimated to be 8.39 per 1000. (95%CI 7.09-9.58). Heart failure, dysrhythmias, the use of hypoglycemic agents, the use of opioids, esophageal disorders and more were also noted to be increased. The full study can be found here.
The excess deaths are concerning. The other associations are at least somewhat suspect. They looked at 379 diagnoses, 380 medication classes, and 62 lab abnormalities. One would expect several positive associations by chance alone. Additionally, association doesn’t mean causality. Patients with a history of COVID-19 may have been seen more frequently leading to a higher rate of diagnosis and medication prescribing. Finally, we can’t be sure that any of the diagnoses are a result of COVID-19. That said, we should take the opportunity to take a good history and do age-appropriate screening in patients we are following up after COVID19.
- Al-Aly, Z., Xie, Y. & Bowe, B. High-dimensional characterization of post-acute sequalae of COVID-19. Nature (2021). https://doi.org/10.1038/s41586-021-03553-9
The Johnson & Johnson/Janssen vaccine has been cleared for use in the United States after a temporary pause secondary to a concern about thrombosis with thrombocytopenia. The Advisory Committee on Immunization Practices (ACIP) concluded that the benefit of the of the Johnson & Johnson/Janssen COVID-19 vaccine outweighs the risk vis-à-vis thrombosis with thrombocytopenia. These cases were seen primarily in women 18-49 years of age and a warning has been added to the Emergency Use Authorization (EUA).
To put this in perspective, the BMJ notes that an unpublished study from the University of Oxford suggests that cerebral venous thrombosis occurs in 39 per million cases of COVID-19 compared to 4 per million in those receiving the Johnson & Johnson/Janssen vaccine (RR 6.36, p<0.001). The EUA and information for patients and providers can be found here.
- MacNeil JR, Su JR, Broder KR, et al. Updated Recommendations from the Advisory Committee on Immunization Practices for Use of the Janssen (Johnson & Johnson) COVID-19 Vaccine After Reports of Thrombosis with Thrombocytopenia Syndrome Among Vaccine Recipients — United States, April 2021. MMWR Morb Mortal Wkly Rep 2021;70:651-656. DOI: http://dx.doi.org/10.15585/mmwr.mm7017e4
- Covid-19: Risk of cerebral blood clots from disease is 10 times that from vaccination, study finds. BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n1005 (Published 16 April 2021)
- U.S. FDA. Janssen COVID-19 Vaccine. Updated April 23, 2021. Available at https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/Janssen-covid-19-vaccine
There are new CDC recommendations for outdoor mask use in those who are fully vaccinated and who are not immunocompromised. Among the points (verbatim):
- Immunocompromised individuals need to consult their healthcare provider about these recommendations, even if fully vaccinated.
- Fully vaccinated people no longer need to wear a mask outdoors, except in certain crowded settings and venues.
- Fully vaccinated workers no longer need to be restricted from work following an exposure as long as they are asymptomatic.
- Fully vaccinated residents of non-healthcare congregate settings no longer need to quarantine following a known exposure.
- Fully vaccinated people can visit with other fully vaccinated people indoors without wearing masks or physical distancing.
- CDC: COVIC-19. Interim Public Health Recommendations for Fully Vaccinated People. Updated, April 29th Available at https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html
Finally, the CDC has released new guidelines for safe interactions at summer camps. Those working in such settings should review these recommendations. They can be found here.
- CDC: COVID-19. Guidance for Operating Youth and Summer camps During COVID-19. Updated 24 April 2021. Available at https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/summer-camps.htm
April 6th through April 20th
Welcome to the McGraw-Hill COVID-19 channel. In this bi-weekly update we have information on COVID-19 and DVT incidence in outpatients, information about vaccine-induced immune thrombotic thrombocytopenia (VITT) associated with the AstraZeneca and the Johnson & Johnson/Janssen vaccines, information on the immune response to SARS-CoV-2 mRNA vaccines in pregnancy and a link to new recommendations for surface decontamination at home and in public buildings.
The AstraZeneca vaccine is associated with vaccine-induced immune thrombotic thrombocytopenia (VITT) with 62 cases of cerebral venous sinus thrombosis and 24 cases of splanchnic vein thrombosis reported. Six similar cases have been associated with the Johnson & Johnson/Janssen vaccine which has led to a temporary halt in the use of this vaccine in the United States.
The first paper is a report of 23 cases of thrombocytopenia with thrombosis in patients who had gotten the AstraZeneca SARS-CoV-2 vaccine (ChAdOx1 nCoV-19 Vaccination). Presentations included cerebral venous thrombosis (including venous sinus thrombosis) (13), pulmonary embolism, portal vein thrombosis, ischemic stroke, and intracranial hemorrhage. Thirty percent of these cases died. Laboratory evaluation demonstrated an elevated D-dimer and low fibrinogen levels. Notably, 22 of 23 patients had a positive ELISA for anti-PF4 antibodies, the same antibody found in heparin induced thrombocytopenia (HIT). The paper includes a diagnostic and treatment algorithm for VITT which is based on the limited information we have so far. Possible treatments include IVIG, glucocorticoids, and the use of non-heparin anticoagulants when anticoagulation is indicated. Platelet transfusion was associated with progression of thrombosis. They recommend consultation with a hematologist to help guide therapy.
A similar syndrome of cerebral venous sinus thrombosis with thrombocytopenia has been identified in six individuals given the Johnson & Johnson/Janssen vaccine in the United States. It is thought that these may also be associated with anti-PF4 antibodies. These cases have led to a temporary halt in administration of this vaccine in the United States.
Symptoms began three to 13 days after vaccination with a mean time to hospital admission of 15 days post-vaccination. Presenting symptoms included headache (5 cases), backache with subsequent headache (1 case), aphasia, weakness, visual changes nausea, vomiting and abdominal pain. Two patients were diagnosed with portal and splanchnic thromboses.
The CDC suggests that patients seek medical care “urgently” for any of the following within three weeks of the Johnson & Johnson/Janssen vaccine (verbatim):
- severe headache
- new neurologic symptoms
- severe abdominal pain
- shortness of breath
- leg swelling
- tiny red spots on the skin (petechiae)
- new or easy bruising
They point out that these six cases occurred in the setting of almost 7 million vaccinations administered, making this complication exceedingly rare even if causally related. The CDC Health Alert for clinicians can be found here. Clinical information for providers and patients can be found here.
- European Medicine Agency. AstraZeneca’s COVID-19 vaccine: EMA finds possible link to very rare cases of unusual blood clots with low blood platelets. April 7, 2021 available at: https://www.ema.europa.eu/en/news/astrazenecas-covid-19-vaccine-ema-finds-possible-link-very-rare-cases-unusual-blood-clots-low-blood
- Scully M, Singh D, Lown R, et. al. Pathologic Antibodies to Platelet Factor 4 after ChAdOx1 nCoV-19 Vaccination. April 16th 2021 available at https://www.nejm.org/doi/full/10.1056/NEJMoa2105385
- CDC, Emergency Preparedness and Response Health Alert Network, Cases of Cerebral Venous Sinus Thrombosis with Thrombocytopenia after Receipt of the Johnson & Johnson COVID-19 Vaccine April 13th 2021 available at https://emergency.cdc.gov/han/2021/han00442.asp
- CDC, COVID-19. Recommendation to Pause the Use of Johnson & Johnson’s Janssen COVID-19 Vaccine. April 16, 2021 available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/JJUpdate.html
The immune response to SARS-CoV-2 mRNA vaccines administered during pregnancy or lactation is robust and similar to the response in non-pregnant controls. This is a prospective cohort study of antibody response to either the Moderna or Pfizer/BioNTech SARS-CoV-2 mRNA vaccine in 84 pregnant patients, 21 lactating patients, and 16 non-pregnant patients. Vaccine induced antibody levels were also compared to those in 37 pregnant women who were diagnosed with COVID-19.
Vaccine induced antibody levels were not statistically different between pregnant, lactating, and non-pregnant women (p=0.24). Vaccine induced antibody levels were higher than those secondary to COVID-19 infection during pregnancy (p<0.0001). Neutralizing antibodies were found in all umbilical cord samples (N=10) as well as in in all breast milk samples tested.
This is the first data we have looking at the immune response to the two mRNA COVID-19 vaccines in pregnancy. While the numbers are small, the data is reassuring; vaccination during pregnancy seems to generate an adequate immune response and the antibody is transferred to the neonate via the placenta and breast milk. The full study can be found here.
- Gray KJ, Bordt EA, Atyeo C, et.al. COVID-19 vaccine response in pregnant and lactating women: A cohort study, American Journal of Obstetrics and Gynecology (2021), doi: https://doi.org/10.1016/j.ajog.2021.03.023.
The risk of DVT is not elevated in outpatients with a positive SARS-CoV-2 test when compared to those who are SARS-CoV-2 negative. It is clear that inpatients with COVID-19 have an elevated risk of venous thromboembolism (VTE). How about outpatients? This is a retrospective study of 220,588 patients of whom 11.8% tested positive for SARS-CoV-2. They looked at the risk of VTE in the 30 days after testing. A new VTE was found in 0.8% of those who tested positive for SARS-CoV-2 (198 patients) and 0.5% (1008 patients) in those who tested negative for SARS-CoV-2 (p<0.001). However, this difference was entirely explained by those patients who were hospitalized; the risk for VTE in outpatients was the same regardless of SARS-CoV-2 status (1.8 vs. 2.2. cases/1000, p=0.16)
This study suffers from a lack of standardized testing in all patients which would have been impractical given the size of the cohort. The authors also point out that VTE testing patterns may have changed because of SARS-CoV-2, which may have caused some patients not to seek care. However, even with these limitations the risk of a VTE diagnosis in those COVID-19 patients treated as outpatients seems low. The full study can be found here.
- Roubinian NH, Dusendang JR, Mark DG, et al. Incidence of 30-Day Venous Thromboembolism in Adults Tested for SARS-CoV-2 Infection in an Integrated Health Care System in Northern California. JAMA Intern Med. Published online April 05, 2021. doi:10.1001/jamainternmed.2021.0488
Briefly, the CDC has changed SARS-CoV-2 surface cleaning guidelines for non-healthcare facilities and individual homes. The recommendations now differentiate between when to clean with soaps and detergents and when to use a disinfectant. They also note that if it has been greater than 24 hours since an area has been exposed to an individual with COVID-19 that disinfection is not necessary; routine cleaning will do. The guidelines are nuanced and not easily summarized.
- CDC, COVID-19: Cleaning and Disinfecting Your Home: Every Day and When Someone is Sick, April 5, 2021. Available at: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/disinfecting-your-home.html
- CDC, COVID-19: Cleaning and Disinfecting Your Facility: Every Day and When Someone is Sick, April 5, 2021. Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html
March 24th through April 5th
Welcome to the McGraw-Hill COVID-19 channel. This week we have information on a new FDA page that tracks mutations and how the mutations effect testing results, information on increased mortality with the British Variant B.1.1.7, information on enhanced communication with patients using an adaptive mask with a clear window, and demographic information about mental health problems related to COVID-19. Finally, bamlanivimab use as a single agent has been halted in the United States.
The FDA is maintaining a website that tracks SARS-CoV-2 variants and the impact these variants have on the validity of testing. There are now multiple variants of the SARS-CoV-2 virus in circulation. The FDA notes that depending on the variant and the test, there may be more false-negative tests. They recommend using a test that has multiple genetic targets to reduce the impact of genetic variations on the validity of tests. Test results should always be interpreted in conjunction with the clinical presentation. If the patient is symptomatic and a false negative test is suspected, repeat testing with a different diagnostic test should be considered. The tests that have been impacted by viral mutations as of 3/30/2021 include:
- Accula SARS-CoV-2 Test (Mesa Biotech Inc.)
- Linea COVID-19 Assay Kit (Applied DNA Sciences, Inc.)
- TaqPath COVID-19 Combo Kit (Thermo Fisher Scientific, Inc.)
- Xpert Xpress SARS-CoV-2, Xpert Xpress SARS-CoV-2 DoD, Xpert Omni SARS-CoV-2 (Cepheid)
This makes it more important to know what variants of SARS-CoV-2 are endemic locally and what test your laboratory is using. Complete information can be found here.
- US FDA. SARS-CoV-2 Viral Mutations: Impact on COVID-19 Tests. https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/sars-cov-2-viral-mutations-impact-covid-19-tests
Patient communication is enhanced when providers use a clear mask.
Communication is critical in medicine, especially now. This is a study of communication between surgeons and patients using a traditional mask or a clear mask. Two-hundred patient visits were randomized to visits in which one of 15 surgeons used either a standard surgical mask or a clear mask (equivalent to a surgical mask in efficacy (ASTM level 3)). High risk contacts in whom an N-95 mask was required were excluded from the trial. Several domains were examined including explaining, listening, answering questions, empathy, patient trust in surgeon decisions and comfort with the operative surgeon. More patients rated the surgeon higher in empathy (99% vs. 85%), had trust in the surgeon’s decision making (94% vs 72%), and believed the surgeon explained things clearly (95% vs. 78%) (p<0.001 for all) when the surgeon wore a clear mask. Overall, patients preferred the clear mask. The surgeons weren’t as pleased and worried about the safety of the clear masks with only 47% being positive about the experience on a 4-point Likert scale.
This is a small study; however, at least some communication is enhanced by the use of clear masks. Given the difficulty of patient communication in the best of times, anything that helps is welcome. The full study can be found here.
- Kratzke IM, Rosenbaum ME, Cox C, Ollila DW, Kapadia MR. Effect of Clear vs Standard Covered Masks on Communication With Patients During Surgical Clinic Encounters: A Randomized Clinical Trial. JAMA Surg.Published online March 11, 2021. doi:10.1001/jamasurg.2021.0836
Mortality is increased in those infected with the British SARS-Co-V2 variant B.1.1.7 when compared to the wild type. Two recent articles examine the mortality from the B.1.1.7 SARS-CoV-2 variant when compared to the wild type.
The first study from the BMJ is a community based matched cohort study of 109,812 individuals, half with the B.1.1.7 variant and half with wild type virus based on a positive PCR and viral genetic testing. The outcome was mortality, either in the hospital or in the community. The hazard ratio for death with the British variant when compared to the wild-type virus was 1.64 (95% CI 1.32-2.04, p <0.001). The overall absolute risk ranged from 2.4-4.1 deaths per 1000 cases.
The second study from Nature looked at 1,146,534 PCR positive SARS-CoV-2 individuals in whom the genetic subtype of the SARS-CoV-2 was identified. Of these, there were 4,945 deaths. The death rate was adjusted for age, sex, care home residence, etc. The absolute mortality varied depending on patient age, but was higher in those with the B22.214.171.124 variant (overall hazard of death 61%(42%-82%) higher). The absolute risk increased by age but was <1% in those less than age 70.
The B.1.1.7 virus variant seems both more contagious and more deadly. Both Moderna and Pfizer/BioNTech have released statements that their respective vaccines are effective against the B.1.1.7 strain which is somewhat reassuring.
- Challen R, Brooks-Pollock E, Read J M, Dyson L, Tsaneva-Atanasova K, Danon L et al. Risk of mortality in patients infected with SARS-CoV-2 variant of concern 202012/1: matched cohort study BMJ 2021; 372 :n579 doi:10.1136/bmj.n579
- Davies, N.G., Jarvis, C.I., CMMID COVID-19 Working Group. et al. Increased mortality in community-tested cases of SARS-CoV-2 lineage B.1.1.7. Nature (2021). https://doi.org/10.1038/s41586-021-03426-1
The CDC has released more data on the mental health effects of the SARS-CoV-2 pandemic. This is a study conducted between August 2020 and February 2021 looking at the social and economic impacts of the COVID-19 pandemic. Phase 3 of the study, from August 2020 to February 2021 included 358,977 individuals. The findings include an anxiety or depressive disorder in 41.5% of respondents, up from 36% in the prior period (August 2020-December 2020). This increase was especially acute in those 18-29 years of age and those with less than a high school education. Unmet mental health needs were reported by 11.7%.
This study emphasizes that the pandemic continues to take its toll on the mental health of Americans. We should remain vigilant for mental health concerns among our patients. The full study can be found here.
- Vahratian A, Blumberg SJ, Terlizzi EP, Schiller JS. Symptoms of Anxiety or Depressive Disorder and Use of Mental Health Care Among Adults During the COVID-19 Pandemic — United States, August 2020–February 2021. MMWR Morb Mortal Wkly Rep 2021;70:490–494. DOI: http://dx.doi.org/10.15585/mmwr.mm7013e2external icon.
Briefly, the FDA withdrew bamlanivimab as a single agent from distribution on March 24th, 2021 because of a lack of efficacy against emerging SARS-CoV-2 strains. They recommend the combination of bamlanivimab/estesevimab as an alternative for high-risk outpatients over 12 years of age who weigh at least 40kg. High risk criteria included a BMI ≥35, chronic kidney disease, sickle cell disease, diabetes, patients on immunosuppressives, and more. The full fact sheet for providers can be found here. This document includes indication, dosing, preparation, and administration. The Emergency Use Authorization for bamlanivimab/estesevimab can be found here.
- FDA Fact Sheet for Health Care Providers: Emergency Use Authorization of Bamlanivimab and Estesevimab. https://www.fda.gov/media/145802/download
- The Emergency Use Authorization for bamlanivimab/estesevimab can be found here. Note that this is more general information, and the Fact Sheet for Health Care Providers provides more details.
March 11th through March 23rd
Welcome to the McGraw-Hill AccessMedicine COVID-19 channel. This week we have information on the use of the SOFA score in COVID-19, information on the lack of benefit of a single dose of Vitamin D in those hospitalized with COVID-19, new guidelines on nursing home visits, a change in the CDC recommendations about returning to school in a safe fashion and an FDA warning about false positive SARS-CoV-2 (and influenza) results with one of Roche’s testing kits.
The Sequential Organ Failure Assessment (SOFA) score is a poor predictor of outcome in intubated patients with COVID-19. The SOFA score is a measurement of organ failure, which includes evaluation of pulmonary function, hepatic function, CNS function, renal function, coagulation function, and neurologic function. It is used in the ICU to determine which patients have a high risk of death.
This is a retrospective study of the predictive value of the SOFA score for mortality in sequential patients with COVID-19 pneumonia from 18 ICUs. All patients were intubated 4 or more hours after requiring oxygen therapy.
2,546 patients were screened, of whom 675 met the criteria for participation and had adequate documentation to allow the calculation of a SOFA score. They used the worst SOFA value within the 48-hours preceding intubation and calculated the area under the curve. 59% died or were admitted to hospice. The SOFA score performed poorly at predicting mortality (area under the curve of 0.55-0.63) and was a worse predictor than simply using age (area under the curve 0.62-0.70) p=0.02).
Trying to predict mortality is always a difficult endeavor and in intubated COVID-19 patients the pre-intubation SOFA score is not a good predictor of survival. This is important as we allocate vital resources such as ventilators. We should not use the pre-intubation SOFA score to decide who gets critical resources. The full study can be found here.
- Raschke RA, Agarwal S, Rangan P, Heise CW, Curry SC. Discriminant Accuracy of the SOFA Score for Determining the Probable Mortality of Patients With COVID-19 Pneumonia Requiring Mechanical Ventilation. Published online February 17, 2021. doi:10.1001/jama.2021.1545
A single high dose of Vitamin D administered to patients with “moderate to severe” COVID-19 failed to improve length of stay, mortality, admission to the intensive care unit, or need for mechanical ventilation. This was a randomized, double-blind, placebo-controlled trial of 240 patients with “moderate to severe” COVID-19 which looked at the effect of vitamin D on length of stay, mortality, need for intensive care, and need for mechanical ventilation. “Moderate to severe” was defined as, “respiratory rate greater than 24 breaths per minute, oxygen saturation less than 93% while breathing room air, or risk factors for complications” (e.g diabetes, obesity, hypertension, immunosuppression, etc.). One hundred and twenty patients received a single oral dose of vitamin D3 200,000 IU and 120 patients received placebo. After treatment, 87% of patients in the vitamin D group had a vitamin D level within the normal range compared to 11% in the control group.
There was no difference in outcomes in any domain. This includes the patients who were vitamin D deficient at baseline.
One weakness of this study is that only 62% of patients had PCR confirmed COVID-19; the rest of the diagnoses were made on clinical criteria (appropriate CT scan and an influenza like illness). Additionally, those getting vitamin D got only a single dose and it was administered after they were symptomatic. We still don’t know how vitamin D will perform in other settings. However, at least in this study population, there was no benefit. The full study can be found here.
- Murai IH, Fernandes AL, Sales LP, et al. Effect of a Single High Dose of Vitamin D3 on Hospital Length of Stay in Patients with Moderate to Severe COVID-19: A Randomized Clinical Trial. 2021;325(11):1053–1060. doi:10.1001/jama.2020.26848
The Centers for Medicare and Medicaid Services (CMS), along with the CDC, has relaxed guidelines for nursing home visits. The new guidelines allow for visitation with some restrictions. From the guidelines vebatim:
"Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission (note: compassionate care visits should be permitted at all times).”
“These scenarios include limiting indoor visitation for:
- Unvaccinated residents, if the nursing home’s COVID-19 county positivity rate is >10% and <70% of residents in the facility are fully vaccinated.
- Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met the criteria to discontinue Transmission-Based Precautions (https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html); or
- Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release”
There are also specific recommendations for visitations when there is a new case of COVID-19 in a staff or resident. These are detailed and not easily summarized.
The guidelines note that outdoor visitation is preferred if possible. All basic infection control measures should remain in place, including mandatory mask wearing, social distancing of at least six feet, hand washing, surface cleaning and, resident and staff testing (see here), etc. Those interested should review the complete guideline, which is available here.
- CMS. “Nursing Home Visitation-COVID-19 (REVISED 3/10/2021). Available at https://www.cms.gov/files/document/qso-20-39-nh-revised.pdf
The CDC has updated the guideline for returning to in person learning in schools. These are nuanced and do not simply reduce physical distancing to three feet as has been reported in the United States press. The guideline recognizes the critical role of education including the social aspects of school such as food access and allowing parents to return to work. The overriding principle is to keep schools open if it is safe to do so. The guideline states that, “K–12 schools should be the last settings to close after all other prevention measures in the community have been employed, and the first to reopen when they can do so safely.” The guideline also stratifies recommendations based on local community transmission. Among the recommendations are:
Physical Distancing (verbatim with added emphasis)
- Between students in classrooms
- In elementary schools, students should be at least three feet apart.
- In middle schools and high schools, students should be at least three feet apart in areas of low, moderate, or substantial community transmission. In areas of high community transmission, middle and high school students should be six feet apart if cohorting is not possible.
Maintain six feet of distance in the following settings:
- Between adults (teachers and staff), and between adults and students, at all times in the school building. Several studies have found that transmission between staff is more common than transmission between students and staff, and among students, in schools.
- When masks cannot be worn, such as when eating.
- During activities when increased exhalation occurs, such as singing, shouting, band, or sports and exercise. Move these activities outdoors or to large, well-ventilated space, when possible.
- In common areas such as school lobbies and auditoriums.”
Other recommendations address the universal use of masks in the school as well as on school buses and other transportation (with exceptions for some students with disabilities), cohorting and maintaining six feet of distance between cohorts, increasing ventilation, including on school buses, having all desks facing the same direction and more.
Those interested should review the complete recommendation. You can find the full recommendation here.
- CDC. COVID-19: Operational Strategy for K-12 Schools through Phased Prevention. Updated 19 March 2021. Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/operation-strategy.html
The FDA is warning about false positive COVID-19 results in patients tested with the “Roche Molecular Systems, Inc. (Roche) cobas SARS-CoV-2 & Influenza A/B Nucleic Acid Test for use on the cobas Liat System”. This is dues to two potential problems: leaking assay tubes which may cause a false positive influenza B and abnormal PCR cycling which may cause a false positive assay for influenza A, B or SARs-CoV-2. The recommendation is to:
- “Monitor for unexpected clusters of positive Flu B results, as this may indicate the cobas Liat System has experienced a tube leak.
- Repeat tests when two or three analytes are positive. Different results on the repeat test may indicate abnormal PCR cycling.
- Stop using the cobas Liat System and contact Roche if you suspect either of these two issues has occurred.”
- US FDA, Potential for False Results with Roche Molecular Systems, Inc. cobas SARS-CoV-2 & Influenza Test for use on cobas Liat System-Letter to Clinical Laboratory Staff, Point-of-Care Facility Staff, and Health Care Providers. Available at: https://www.fda.gov/medical-devices/letters-health-care-providers/potential-false-results-roche-molecular-systems-inc-cobas-sars-cov-2-influenza-test-use-cobas-liat
Week of March 3rd through March 10th
Welcome to the AccessMedicine COVID-19 channel. This week we have information on the use of ivermectin in outpatients with COVID-19, new guidelines for social interaction for those who are completely immunized and new recommendations for tocilizumab from the NIH.
Ivermectin was ineffective in patients with mild COVID-19. This is a randomized, double blind, placebo control trial of ivermectin treatment in 476 patients with COVID-19 who had mild disease for less than 7 days (only 200 in each group were analyzed because of a labeling mix-up). Mild was defined as not requiring high-flow nasal oxygen or more intensive respiratory support. The outcome was resolution of symptoms.
There was no difference between the two groups in time to resolution (9-13 days in both groups, HR 1.07 (95% CI 0.87-1.32, p=0.53). Progression to multiorgan failure was also the same in the two groups.
The majority of these patients had no limitations of activity at baseline and were outpatients. However, at least in this population with mild COVID-19, ivermectin did not prevent progression to more severe disease or hasten the resolution of symptoms. More studies will no doubt be forthcoming. The full study can be found here.
- López-Medina E, López P, Hurtado IC, et al. Effect of Ivermectin on Time to Resolution of Symptoms Among Adults With Mild COVID-19: A Randomized Clinical Trial. Published online March 04, 2021. doi:10.1001/jama.2021.3071
The CDC has updated the social contact guidelines for those who have been fully vaccinated. In order to be considered fully vaccinated one needs to be two weeks out after the second dose of the Pfizer/BioNTech or Moderna vaccines or 2 weeks out from the single dose Johnson and Johnson Vaccine. Here is what has, and has not, changed.
There is no change in recommendations for public spaces. All individuals should continue to wear a mask, maintain 6 feet of social distancing, and avoid crowded or poorly ventilated spaces. Travel is still not recommended.
If you have been fully vaccinated, you can:
- “Gather indoors with fully vaccinated people without wearing a mask.”
- Visit one other household without a mask if all of the individuals in the household are considered low risk for severe COVID-19 disease. This is more restrictive than it might seem at first glance. Those considered at increased risk include those with:
- Chronic kidney disease
- COPD (chronic obstructive pulmonary disease)
- Down Syndrome
- Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
- Immunocompromised state (weakened immune system) from solid organ transplant
- Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)
- Severe Obesity (BMI ≥ 40 kg/m2)
- Sickle cell disease
- Type 2 diabetes mellitus
- Fully immunized individuals do not need to quarantine after being exposed to COVID-19. However, fully immunized individuals still do need to track symptoms and isolate/get tested symptoms develop.
This does not apply to vaccinated individuals living in a group setting (including group homes, correctional facilities, long term care centers, etc.). If you live in one of these settings and are exposed to COVID-19, you should still quarantine for 14 days and get tested, even if asymptomatic.
The full recommendations can be found here.
The list of high risk conditions can be found here.
CDC, COVID-19: When You Have Been Fully Vaccinated. How to Protect Yourself and Others. Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated.html
Tocilizumab has been added to the NIH COVID-19 protocol for some hospitalized patients who are “exhibiting rapid respiratory decompensation”. This is verbatim from the recommendation:
“The Panel recommends the use of tocilizumaba (single intravenous dose of 8 mg/kg of actual body weight, up to 800 mg) in combination with dexamethasone (6 mg daily for up to 10 days)b in certain hospitalized patients who are exhibiting rapid respiratory decompensation due to COVID-19.c The patients included in this population are:
- Recently hospitalized patientsd who have been admitted to the intensive care unit (ICU) within the prior 24 hours and who require invasive mechanical ventilation, noninvasive mechanical ventilation (NIV), or high-flow nasal canula (HFNC) oxygen (>0.4 FiO2/30 L/min of oxygen flow) (BIIa); or
- Recently hospitalized patientsd (not in the ICU) with rapidly increasing oxygen needs who require NIV or HFNC and have significantly increased markers of inflammation (BIIa).” They note that a C-reactive protein (CRP) of ≥ 75mg/L has been used in trials. This is the same CRP recommendation that is found in the Infectious Disease Society of America (IDSA) guidelines.
a Use of tocilizumab should be avoided in patients with any of the following: (1) significant immunosuppression, particularly in those with a history of recent use of other biologic immunomodulating drugs; (2) alanine transaminase >5 times the upper limit of normal; (3) high risk for gastrointestinal perforation; (4) an uncontrolled, serious bacterial, fungal, or non-SARS-CoV-2 viral infection; (5) absolute neutrophil count <500 cells/µL; or (6) platelet count <50,000 cells/µL.
b As an alternative to dexamethasone, corticosteroids at a dose equivalent to dexamethasone 6 mg are acceptable (see Corticosteroids).
c Respiratory decompensation should be due to progressive COVID-19 and not due to alternative causes, such as volume overload or asthma exacerbation.
d For example, within 3 days. Median days of hospitalization until randomization was 1.2 days (IQR 0.8–2.8 days) in REMAP-CAP and 2 days (IQR 1–5 days) in the RECOVERY trial.
The full recommendation can be found here.
Those contemplating the use of tocilizumab should familiarize themselves with the entire protocol.
- NIH COVID-19 Treatment Guidelines. The COVID-19 Treatment Guidelines Panel’s Statement on the Use of Tocilizumab for the Treatment of COVID-19. https://www.covid19treatmentguidelines.nih.gov/statement-on-tocilizumab/
- IDSA Guidelines on the Treatment and Management of Patients with COVID-19. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/
February 18th through March 2nd
Welcome McGraw-Hill’s COVID-19 channel. This week we have information on full anticoagulation versus prophylactic dose anticoagulation for those admitted for COVID-19, new recommendations from the Infectious disease Society of America for the use of tocilizumab, information on Vitamins C, D, and zinc and how they may (or may not) help, and information on persistent symptoms in those with mild to moderate COVID-19.
Vitamin C (Ascorbic Acid) and Zinc fail to shorten the duration of COVID-19 symptoms in outpatients. This is a randomized, open label, trial of 214 outpatients with COVID-19 comparing high dose vitamin C (8000mg) and zinc (50mg), either by themselves or in combination, to a placebo. Participants rated their symptoms including fever, shortness of breath, fatigue and cough on a 4-point scale. The outcome was the duration of symptoms. The study initially called for the enrollment of 520 participants but was stopped at the interim analysis for lack of benefit. A 50% reduction in symptoms occurred in 4.4 days with placebo, 3.7 days with ascorbic acid, 5.5 days for zinc and 5.9 days for the combined zinc plus ascorbic acid group. There was no statistical difference between the groups in the symptom score (p=0.45). Additionally, there were no differences in death or hospitalization rates.
At least in ambulatory outpatients with COVID-19 neither zinc nor vitamin C provided any benefit. This cautionary tale reminds us that, as with hydroxychloroquine, plausible biologic mechanisms don't necessarily translate into clinical usefulness. The full study can be found here.
- Thomas S, Patel D, Bittel B, et al. Effect of High-Dose Zinc and Ascorbic Acid Supplementation vs Usual Care on Symptom Length and Reduction Among Ambulatory Patients With SARS-CoV-2 Infection: The COVID A to Z Randomized Clinical Trial
Two studies suggest there is no benefit to full dose anticoagulation in those hospitalized with COVID-19 when compared to prophylactic dose. The first study was an observational study of anticoagulation in critically ill ICU patients with COVID-19. It looked at the effect of full dose anticoagulation within the first 48 hours of admission to the ICU on survival compared to prophylactic dose anticoagulation. They used logistic regression to account for differences between the groups. In this study, male gender and higher D-dimer on day 1 (>1 mg/L or 1000ng/mL) were associated with venous thromboembolic disease. The risk of thromboembolic disease increased as the D-dimer increased. Patients were followed for a median 27 days. 1,066 of the 2,809 patients (38.0%) died, including 179 (46.6%) treated with early therapeutic anticoagulation and 887 (36.6%) treated with prophylactic dose anticoagulation. 2.8% of the anticoagulated patients had a major bleeding event. The hazard ratio for death was not different between the groups (hazard ratio, 1.12 [CI, 0.92 to 1.35]). The full study can be found here. 
The second study is a meta-analysis of 35 studies looking at full anticoagulation, prophylactic dose anticoagulation and no anticoagulation on the rate of symptomatic or asymptomatic venous thromboembolism including DVT and PE. The secondary outcomes included arterial thrombosis, bleeding and death. Thirty-five studies included 4,685 patients who were evaluated for venous thromboembolism, 1,464 patients evaluated for arterial thrombosis (e.g. myocardial infarction, stroke) and 6,393 for bleeding events. Thrombosis was less common in all anticoagulation groups when compared to the group that got no anticoagulation (p=0.009). There was no difference between the prophylactic dose anticoagulation and full anticoagulation. Bleeding was 6.3% in the full anticoagulation group versus 1.7% with prophylaxis doses. The full study can be found here. 
These two studies show no difference between full anticoagulation and prophylaxis dose treatment in overall thromboembolic events. The meta-analysis is well done but is limited by the lack of randomized, controlled studies and the heterogeneity of the studies. None-the-less, full dose anticoagulation does not seem more effective than prophylactic dose anticoagulation in preventing venous thromboembolism. Hopefully randomized trials will be coming.
-  Hanny Al-Samkari, Shruti Gupta, Rebecca Karp Leaf, et al. Thrombosis, Bleeding, and the Observational Effect of Early Therapeutic Anticoagulation on Survival in Critically Ill Patients With COVID-19. Ann Intern Med. [Epub ahead of print 26 January 2021]. doi:10.7326/M20-6739
-  Patell R, Chiasakul T, Bauer E, Zwicker JI. Pharmacologic Thromboprophylaxis and Thrombosis in Hospitalized Patients with COVID-19: A Pooled Analysis. Thromb Haemost. 2021 Jan;121(1):76-85. doi: 10.1055/s-0040-1721664. Epub 2020 Dec 30. PMID: 33378787; PMCID: PMC7869062.
The Infectious Disease Society of America (IDSA) has added tocilizumab to its list of recommended treatments. They note that while there is no mortality benefit (RR 0.91; 95%CI 0.79-1.04) there is a lower risk of the combination of death, need for mechanical ventilation/ECMO and ICU care (RR: 0.83 95% CI 0.77-0.89). The certainty of evidence for both outcomes is moderate.
- Appropriate patients include those with elevated inflammatory markers (for example a CRP of greater than or equal to 75mg/L) and who are also severely or critically ill.
- Serious illness is defined as a SpO2 of <94% on room air and critically ill would include those on a ventilator, ECMO, or with end organ dysfunction (including ARDS).
- Tocilizumab should be added to dexamethasone, which per the IDSA “remains the standard of care.”
- The IDSA go on to say that, “Patients, particularly those who respond to steroids alone, who put a high value on avoiding possible adverse events of tocilizumab and a low value on the uncertain mortality reduction, would reasonably decline tocilizumab.”
Note that the IDSA recommendations are different than the NIH guidelines. The NIH guidelines, which are more restrictive, can be found here. The full IDSA recommendations can be found here.
A free IDSA App for iOS and Android which contains guidelines for COVID-19 and multiple other infectious diseases can be found on the Apple App store and on Google Play.
- IDSA Guidelines on the Treatment and Management of Patients with COVID-19. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/
Finally, a substantial minority of COVID-19 patients including those with mild or moderate disease still had some symptoms after “recovering” from COVID-19. This is a study of 177 participants who completed a survey after having COVID-19. The great majority of surveys were completed between 120 and 240 days after the index illness. Of these patients, 11.6% had asymptomatic COVID-19, 84.7% had mild illness and 9% required hospitalization. Overall, 33% of outpatients and 31% of inpatients reported persistent symptoms including fatigue, loss of sense of smell or taste and “brain fog.” Eight percent noted a problem with at least one activity of daily living (ADL).  The full study can be found here.
There is now an official name for “long-hauler syndrome” which is “post-acute sequelae of COVID-19”, or “PASC”.  This is a small study and rightly the authors did not compare the groups given the small number of participants. It reminds us that those with PASC include patients who had mild to moderate COVID-19. That eight percent had problems with at least one ADL should prompt us to ask patients who have had COVID-19 whether they need additional help at home.
-  Logue JK, Franko NM, McCulloch DJ, McDonald D, Magedson A, Wolf CR, Chu HY. Sequelae in Adults at 6 Months After COVID-19 Infection. JAMA Netw Open. 2021 Feb 1;4(2):e210830. doi: 10.1001/jamanetworkopen.2021.0830. PMID: 33606031.
-  NIH Directors Blog. Available at https://directorsblog.nih.gov/tag/post-acute-sequelae-of-covid-19/
February 5th through February 17th
Welcome to the McGraw-Hill COVID-19 channel. This week we have information on the “best practices” for reopening schools, the tightening of criteria for the use of convalescent serum, a “best practices” note from the FDA on using a single ventilator for two patients, and new recommendations on quarantine after exposure to SARS-CoV-2 in those already vaccinated.
On February 10th, 2021, the CDC changed guidelines regarding quarantine rules in those who have been fully immunized. Allergic contraindications for vaccination have also been updated.
“Vaccinated persons with an exposure to someone with suspected or confirmed COVID-19 are not required to quarantine if they meet all of the following criteria (verbatim):
- Are fully vaccinated (i.e., ≥2 weeks following receipt of the second dose in a 2-dose series, or ≥2 weeks following receipt of one dose of a single-dose vaccine)
- Are within 3 months following receipt of the last dose in the series
- Have remained asymptomatic since the current COVID-19 exposure”
Vaccinated individuals still need to watch for symptoms and signs for 14 days after exposure and, if symptoms develop, continue to follow isolation procedures.
Hopefully this reduces the burden of quarantine in those vaccinated. Note that the period of modified quarantine only lasts for three months after the completed vaccine series. Also note that following patient symptoms is still crucial.
Regarding allergy and contraindications to mRNA vaccines, the current guideline reads:
“Persons with a known (diagnosed) allergy to polyethylene glycol (PEG), another mRNA vaccine component, or polysorbate, have a contraindication to vaccination. There is a precaution to vaccinate persons with a reaction to a vaccine or injectable therapy that contains multiple components, one of which is PEG, another mRNA vaccine component or polysorbate, but in whom it is unknown which component elicited the immediate allergic reaction. The full vaccination update can be found here.
It is still important to be prepared to treat anaphylaxis after COVID-19 immunization, although it remains a rare occurrence.
- CDC Vaccines & Immunizations, mRNA COVID-19 Vaccines. https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html
The FDA emergency use authorization (EAU) for convalescent serum has been tightened. The new requirements include (verbatim):
- The use of low titer anti-SARS-CoV-2 convalescent plasma is no longer authorized. The new EUA points out that high titer plasma is the only preparation that has been shown effective.
- The use of convalescent plasma is restricted to inpatients and to those outpatients who have impaired humoral immunity (e.g. bone marrow transplant, some chemotherapy, on chronic steroids, etc.).
- The use of convalescent plasma in those with respiratory failure requiring intubation has not been shown to be of benefit.
- FDA In Brief: FDA Updates Emergency Use Authorization for COVID-19 Convalescent Plasma to Reflect New Data https://www.fda.gov/news-events/fda-brief/fda-brief-fda-updates-emergency-use-authorization-covid-19-convalescent-plasma-reflect-new-data
The CDC has released new guidelines for reopening schools. These are detailed guides for school reopening including details on mask wearing, physical distancing, handwashing, maintaining and cleaning facilities and contact tracing. They do not mandate vaccines for teachers but rather suggest that they should be prioritized for vaccination along with other frontline workers. Importantly, they are not mandating a return to in-person learning; this is still up to state and local governments. But these guidelines show how to do it safely. These guidelines are detailed and can be found here
- DC COVID-19 Schools & Child Care https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/index.html
Lastly, the FDA has released a best practices recommendation for using ventilator splitters. The current recommendations include (verbatim):
“Health care providers and facilities should review the considerations listed below:
- Consider non-invasive ventilation such as high flow nasal oxygen or non-invasive positive pressure ventilation as a first option prior to using an authorized ventilator splitter.
- If invasive ventilation using an authorized ventilator splitter is the only option:
- Limit sharing of ventilation to two patients,
- Try to match patients based on similar ventilatory requirements,
- Limit duration of sharing ventilation to 48 hours,
- If possible, reserve at least one single patient ventilator for emergencies or to wean a patient off ventilation support
- Consider updated ventilator sharing protocols, such as the New York Presbyterian Ventilator Sharing Protocol: Dual-Patient Ventilation with a Single Mechanical Ventilator for Use during Critical Ventilator Shortages to minimize risk.
- The recent literature indicates that ventilator splitters that incorporate these features may reduce certain risks:
- One-way valves in the breathing circuit,
- Flow restrictors or pressure regulators at each inspiratory limb of the circuit,
- Individual positive end-expiratory pressure (PEEP) valves,
- Inspiratory and expiratory tidal volume sensors, and
- Pressure sensors.”
Hopefully we are beyond the peak that led to ventilator shortages. None-the-less this is important information for those working on inpatient units in case the situation arises again. The full document can be found here.
- FDA: Using Ventilator Splitters During the COVID-19 Pandemic - Letter to Health Care Providers https://www.fda.gov/medical-devices/letters-health-care-providers/using-ventilator-splitters-during-covid-19-pandemic-letter-health-care-providers
Week of January 28th through February 4th
Welcome to the McGraw Hill COVID-19 channel. This week we have information about the differences in clinical presentation of the British strain, more information about outcomes in pregnancy, and a revised NIH recommendation on ivermectin (now “insufficient data to recommend either for or against”). We also have a revised NIH recommendation for tocilizumab and sarilumab.
Loss of smell and taste are less common with the British variant B.1.1.7 while sore throat, cough, myalgias and fatigue are more common. This is a report covering cases in England from 15 November 2020 to 16 January 2021 reported by the British Office for National Statistics. They looked at 3583 positive COVID-19 samples of whom 52% were positive for B1.1.7. Fewer patients with the B1.1.7 variant presented with loss of smell and taste, but they were more likely to have cough, myalgias, sore throat and fatigue.
There are two take home points. First, B1.1.7 has rapidly become a common strain in Britain, reflected its increased infectivity. Second, don’t ignore patients with “atypical” symptoms. They may still have COVID-19. The full report can be found here.
Mhase E. Covid-19: Sore throat, fatigue, and myalgia are more common with new UK variant BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n288 (Published 29 January 2021)
We have more data about the outcomes of pregnancy in those infected with SARS-CoV-2. This is a retrospective study using the “Premier Healthcare Database” which encompasses about 20% of US hospitalizations. 406,446 women were hospitalized for delivery between April and November 2020 of whom 1.6% had COVID-19. Overall mortality in those with COVID-19 was low (0.1%) although it was higher than in those with COVID-19 (adjusted OR 26 (CI 95% 11.26—60.38)). Pre-eclampsia (but not eclampsia) was higher in those with COVID-19; stillbirths were the same in both groups. Venous thromboembolism was higher in those with COVID-19 (0.2% versus 0.1% p<0.001). The full study can be found here.
This data is reassuring and consistent with other studies. While risks to the pregnant woman with COVID-19 are higher than in those who are not infected, the absolute risks are still low. The full study can be found here.
Jering KS, Claggett BL, Cunningham JW, et al. Clinical Characteristics and Outcomes of Hospitalized Women Giving Birth with and without COVID-19. JAMA Intern Med. Published online January 15, 2021. doi:10.1001/jamainternmed.2020.9241
NIH guidelines have changed the recommendation for ivermectin to “there are insufficient data to recommend either for or against the use of ivermectin”. This is an upgrade from the previous “recommend against” status. The NIH statement points out that much of the data is not randomized/blinded and that outcomes were often not well defined. They call for more data from randomized controlled studies.
This gives cover for those prescribing ivermectin for COVID-19. By report, randomized controlled studies are in the pipeline which should give “definitive” answers on the use of ivermectin. The full NIH statement can be found here.
NIH COVID-19 Treatment Guidelines. The COVID-19 Treatment Guidelines Panel’s Statement on the Use of Ivermectin for the Treatment of COVID-19, Last Updated: January 14, 2021 https://www.covid19treatmentguidelines.nih.gov/statement-on-ivermectin
Lastly, the status of tocilizumab and sarilumab have also been upgraded to “there are insufficient data to recommend either for or against the use of” for some patients. The panel still recommends against tocilizumab and sarilumab in those not in the ICU. The consideration here is a bit more nuanced than for ivermectin with a separate recommendation for those in the ICU versus those on a regular hospital floor. The panel suggests:
- “For patients who are within 24 hours of admission to the ICU and who require invasive or noninvasive mechanical ventilation or high-flow oxygen (>0.4 FiO2/30 L/min of oxygen flow), there are insufficient data to recommend either for or against the use of tocilizumab or sarilumab for the treatment of COVID-19.
- Although many trials of tocilizumab for the treatment of COVID-19 have included patients who meet the above criteria, the collective data available to date preclude a definitive recommendation for or against the use of the drug.
- In view of the results from the REMAP-CAP trial, some Panel members would administer a single dose of tocilizumab (8 mg/kg of actual body weight, up to 800 mg) in addition to dexamethasone to patients who meet the above criteria and who are also exhibiting rapid progression of respiratory failure.
- Too few patients in REMAP-CAP received sarilumab for the Panel to assess its efficacy in the treatment of patients who met the above criteria.
- For patients who do not require ICU-level care or who are admitted to the ICU but do not meet the above criteria, the Panel recommends against the use of tocilizumab or sarilumab for the treatment of COVID-19, except in a clinical trial (BIIa).”
Even though sarilumab are included together as a class, the panel points out that the studies of sarilumab are limited. For now, tocilizumab has better data. The panel has suggested criteria and a dosing schedule to follow for tocilizumab pending more data on both drugs. The full NIH statement can be found here.
- NIH COVID-19 Treatment Guidelines. The COVID-19 Treatment Guidelines Panel’s Statement on the Use of Tocilizumab (and Other Interleukin-6 Inhibitors) for the Treatment of COVID-19 Last Updated: February 3, 2021 https://www.covid19treatmentguidelines.nih.gov/statement-on-tocilizumab/
Week of January 20th through January 27th
Welcome to the McGraw-Hill COVID-19 channel. This week we have information on the outcome of treating cardiac arrest on the scene versus transporting the patient to the hospital (a protocol that has been adopted in some areas). This discussion is paired with a British Medical Journal (BMJ) note that England’s health and social secretary has rejected a call for indemnity for physicians who have to make resource allocation decisions. We have new information about anaphylaxis with the Moderna vaccine (exceedingly rare) and information on liberalization of the timing of the second vaccination.
“Do not transport” orders are medically justifiable in out-of-hospital cardiac arrest patients who do not have a return of spontaneous circulation at the scene. As hospitals become overwhelmed with COVID-19 patients, decisions will have to be made about the use of limited resources and how to allocate them. For example, should ventilators be used with patients on a “first come first serve” basis, or should there be criteria that exclude someone from being intubated? In response to the moral and legal peril posed by having to make these decisions on a day in and day out basis, a number of physician organizations in Great Britain petitioned the government to indemnify physicians having to make these judgments. This request was denied. The BMJ summary can be found here.
Some systems in the United States have changed their transport criteria for cardiac arrest, asking that patients with a poor prognosis not be transferred as a way to alleviate crowding in the ED and the use of inpatient beds. This study supports that decision. This is a cohort study of 27,750 consecutive patients with an out-of-hospital non-traumatic cardiac arrest. They looked at survival when resuscitation was done only at the scene versus when patients were transported during the arrest. Patients were propensity matched. Survival was 8.5% when resuscitation was done at the scene versus 4.0% 4.6% [95% CI, 4.0%- 5.1%]) if the patient was transported. Neurological outcomes were also better in those resuscitated at the scene. This can possibly be explained by the pauses in resuscitation effort required to move the patient, etc. Of the 10 systems providing data, one site did better with transport, seven did worse and two were neutral.
This supports not immediately transporting patients with a cardiac arrest without return of spontaneous circulation (ROSC). Resuscitation was superior when done at the scene and we can avoid possible SARS-CoV-2 exposure to hospital personnel and alleviate the shortage of bed space. It would be helpful to tease out what was done differently at the site that showed a benefit. But overall, transport during cardiac arrest was harmful. The complete abstract can be found here.
- Dyer Clare. Covid-19: Doctors’ call for legal protection against claims of unlawful killing is rejected BMJ 2021; 372 :n164
- Grunau B, Kime N, Leroux B, et al. Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA. 2020;324(11):1058–1067. doi:10.1001/jama.2020.14185
The interval between vaccines can be lengthened to 6 weeks if absolutely necessary according to the CDC. The recommended interval between vaccine doses is 21 days for the Pfizer/BioNTech vaccine and 28 days for the Moderna vaccine. A four-day grace period earlier than these recommendations is allowed. In some circumstance, it may not be possible to meet this schedule. A 21 January 2021 update to the vaccine schedule allows that “the second dose of Pfizer-BioNTech and Moderna COVID-19 vaccines may be scheduled for administration up to six weeks (42 days) after the first dose.” Delay beyond six weeks is not recommended since we do not have data to support a longer delay. However, if the booster shot cannot be given within six weeks, it is not recommended that the series be restarted; just give the second dose as soon as is possible. Complete vaccine recommendations can be found here.
As the number of people eligible for second doses of a vaccine increases, scheduling may be a problem for some patients. This gives us a bit of leeway if it is not possible to meet the recommended schedule.
- CDC. Interim Clinical Considerations for the Use of mRNA COVID-19 Vaccines Currently Authorized in the United States. https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html
The risk of anaphylaxis with the Moderna SARS-CoV-2 vaccine is exceedingly low. This is a CDC study of the anaphylaxis risk of the Moderna vaccine based on the first 4,041,396 doses given. There were a total of 10 cases of anaphylaxis (2.5 cases per million, about ¼ of the risk of the Pfizer/BioNTech vaccine). Of these, nine occurred within 15 minutes of the vaccine and there were no deaths (although four had to be intubated). It is notable that 108 cases of anaphylaxis were reported, of which only 10 met the criteria for anaphylaxis.. Both the Moderna and the Pfizer/BioNTech vaccines are exceedingly safe when it comes to anaphylaxis.
You may have heard that there was a pause in vaccinating with one batch of the Moderna vaccine in California. After review, vaccination was resumed using the same batch without problem. The full study can be found here.
- MMWR. Allergic Reactions Including Anaphylaxis After Receipt of the First Dose of Moderna COVID-19 Vaccine — United States, December 21, 2020–January 10, 2021. MMWR Morb Mortal Wkly Rep. ePub: 22 January 2021. DOI: http://dx.doi.org/10.15585/mmwr.mm7004e
Week of January 13th through January 19th
Welcome to the McGraw-Hill COVID-19 channel. This week we have information on myocarditis in competitive athletes, a preliminary report of the use of tocilizumab and sariumab in critically ill patients, an interesting study on the development of myopia in school-aged-children who are confined to home and a note from the CDC on the spread of the British variant B1.1.7 in the United States.
Myocarditis is uncommon on MRI in college athletes recovering from COVID-19 and is reflected in usual cardiac markers. This is a retrospective study of 145 sequential college athletes who had asymptomatic, mild or moderate symptoms of COVID-19 and who had a cardiac MRI to look for myocarditis. The age range was 17-23 years, and all patients were “recovered”. Forty-nine percent had mild and 28% had moderate COVID-19 with the rest asymptomatic. No patients were hospitalized. MRIs were done between 11 and 194 days after a positive SARS-CoV-2 test.
Of the 145 students, only two patients (1.4% 95% CI 0.4-4.9%) had evidence of myocarditis on MRI with one of the two having had a positive troponin and one having an abnormal ECG (non-specific ST-T changes).
Four patients had elevated troponins but a negative MRI. Of these, two had only a single elevated troponin and were considered by the authors to be false positive.
As pointed out in the article, the criteria used to diagnose myocarditis on MRI presupposes a high pretest clinical probability, so it is possible that myocarditis was underdiagnosed.
This one study should not change our approach to clearing athletes to return to activities. The Kaiser Permanente Return to Sports Guidelines can be found
here. The American Academy of Pediatrics Guidelines for return to sports can be found here. The full study can be found here.
- Starekova J. et. al. Evaluation for Myocarditis in Competitive Student Athletes Recovering From Coronavirus Disease 2019 With Cardiac Magnetic Resonance Imaging JAMA Cardiol. Published online January 14, 2021. doi:10.1001/jamacardio.2020.7444
Tocilizumab and sarilumab seem to improve survival in patients who are critically ill requiring “organ support”.1 This is a prepublication paper which has not been peer reviewed. This is a randomized study of 353 patients treated with the interleuikin-6 (IL6) antagonist tocilizumab and 48 treated with sarilumab; there were 402 controls. Patients were >18 years of age “with suspected or confirmed COVID-19, admitted to an intensive care unit (ICU) and receiving respiratory or cardiovascular organ support who were classified as severe”.
In another paper, they define “organ support” as: “Respiratory organ support was defined as invasive or noninvasive mechanical ventilation or high-flow nasal cannula if the flow rate was 30 L/min or greater and fraction of inspired oxygen of 0.4 or greater and “cardiovascular organ support as the intravenous infusion of any vasopressor or inotrope”.2
The adjusted odds ratio of survival was 1.66 for tocilizumab, 2.25 for sarilumab with a baseline of 1 in controls.
Why is this paper important? The British government has decided to make tocilizumab and sarilumab available to critically ill patients on the basis of this study. However, the guidelines have not yet changed in the United States. The current Infectious Disease Society of America recommendation (11/22/20) is “Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel suggests against the routine use of tocilizumab. (Conditional recommendation, Low certainty of evidence)”. The full study can be found here.
- The REM-CAP Investigators. Interleukin-6 Receptor Antagonists in Critically Ill Patients with Covid-19 – Preliminary report. medRxiv 2021.01.07.21249390; doi: https://doi.org/10.1101/2021.01.07.21249390
- The Writing Committee for the REMAP-CAP Investigators. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA. 2020;324(13):1317–1329. doi:10.1001/jama.2020.17022
The development of myopia is more common in children age 6-8 confined to home during the SARS-CoV-2 pandemic than during the previous 5 years. This is a prospective, cross-sectional, Chinese study of 123,535 children age 6-13 carried out over 6 years. All children had their vision screened annually. Children age 5, 7, and 8 had a higher incidence of developing myopia during confinement (2020) compared to the years prior to confinement (2015-2019). The rates were age 6: 21.5% vs. 5.7%; age 7: 26.2% vs. 16.2%, age 8: 37.2% vs. 27.7%).
According to the authors, lack of time outdoors as well as increased “near work”, including screen time, have been shown to increase the incidence of myopia. They recommend more outdoor time and less screen time for these young students. They plan to follow the population longitudinally to see if this is a permanent effect. The full study can be found here.
- Wang J, Li Y, Musch DC, et al. Progression of Myopia in School-Aged Children After COVID-19 Home Confinement. JAMA Ophthalmol. Published online January 14, 2021. doi:10.1001/jamaophthalmol.2020.6239
CDC modeling predicts that the British variant of SARS-CoV-2 (B.1.1.7) will become the predominant strain by March. This is a MMWR report modeling the spread of the B.1.1.7 variant in the United States. They note that the B.1.1.7 variant had been found in 10 states as of January 12, 2021. They note that it is likely to become the predominant strain in the US by March even given the current low rate (<0.5% of cases). They discuss the importance of mitigation efforts including masks, social distancing, avoiding crowds, and vaccination. The full report can be found here.
- Galloway SE, Paul P, MacCannell DR, et al. Emergence of SARS-CoV-2 B.1.7 Lineage — United States, December 29, 2020–January 12, 2021. MMWR Morb Mortal Wkly Rep. ePub: 15 January 2021. DOI: http://dx.doi.org/10.15585/mmwr.mm7003e2
Week of January 6th through January 12th
Welcome to the McGraw-Hill COVID-19 channel. This week we have information about the sensitivity of SARS-CoV-2 testing and how it relates to the new variants of SARS-CoV-2. We also have information from Pfizer/BioNTech about the effectiveness of the current vaccine against the “British” variant, strain B 1.1.7 (AKA 20B/501Y.V1, VOC 202012/01). Finally, there is a new study about the long-term consequences of COVID-19 and a new negative study of tocilizumab in those not requiring mechanical ventilation.
The FDA is warning about false negative tests in those infected with SARS-CoV-2 variants. As the genetic makeup of the SARS-CoV-2 varies, so does the sensitivity of testing. The FDA notes a reduced sensitivity of the following tests for the British variant, B 1.1.7 (AKA 20B/501Y.V1, VOC 202012/01):
- TaqPath COVID-19 Combo Kit,
- Linea COVID-19 Assay Kit.
Since these lab tests target multiple sites, the overall sensitivity of the tests has not changed. A third test, the Accula SARS-Cov-2 Test, is undergoing further testing. The FDA recommends the following (verbatim):
- Be aware that genetic variants of SARS-CoV-2 arise regularly, and false negative test results can occur.
- Be aware that tests that use multiple genetic targets to determine a final result are less likely to be impacted by increased prevalence of genetic variants.
- Consider negative results in combination with clinical observations, patient history, and epidemiological information.
- Consider repeat testing with a different test (with different genetic targets) if COVID-19 is still suspected after receiving a negative test result.
There are also specific recommendations for lab staff including an increase in whole genome testing. The complete recommendations can be found here.
The Pfizer/BioNTech vaccine is effective against the British (B 1.1.7) SARS-CoV-2 variant in the lab. This is a prepublication study of the effect of vaccine-induced neutralizing antibodies on the newly described UK variant. They exposed lab generated isotype viruses to the sera of 20 patients who had been previously immunized with the Pfizer/BioNTech vaccine. The outcome was the antibody level required for 50% reduction in infectivity (plaque reduction). There was no difference between the antibody level required for a 50% neutralization of the B 1.1.7 variant versus the unmutated virus (BNT162b2).
The authors point out that there are additional mutations in wild-type virus that they did not account for; they looked only at the one mutation in isolation. The full study can be found here. We are still waiting for the data from Moderna about their vaccine.
- Xie X et al. Neutralization of N501Y mutant SARS-CoV-2 by BNT162b2 vaccine-elicited sera bioRxiv 01.07.425740; doi: https://doi.org/10.1101/2021.01.07.425740
Many hospitalized patients with moderate to severe COVID-19 have residual symptoms 6 months after discharge. This is a study of 2469 patients who were hospitalized for COVID-19; participants were a mean of 186 days post-discharge. Patients were asked about continued symptoms and were stratified according to their inpatient 7-point COVID-19 severity scale.
Overall, 63% percent reported fatigue or muscle weakness while 26% reported difficulty sleeping and 23% reported anxiety. Of those who had a severity scale of 5-6 29% had an impaired 6-minute walking distance. Fifty-six percent of those with a severity score of 5-6 had lung diffusion impairment while 29% if those with a severity score of 4 had diffusion impairment. A CrCl of less than 90 mL/min per 1·73 was found in 35%.
This likely underestimates the problem since 30% of patients were excluded (736 of 2469). Exclusion criteria included the inability to “move freely” (including from osteoarthritis, stroke or pulmonary embolism), those living in a nursing facility and those who had been readmitted. It also doesn’t tell us about sequelae in those who were not hospitalized. Nor is there a control group of those hospitalized with other illnesses. None-the-less it gives us concrete information about problems that may need to be addressed post-hospitalization. The full study can be found here.
- Huang C. et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. The Lancet January 8, 2021 :https://doi.org/10.1016/S0140-6736(20)32656-8
Another negative study of tocilizumab in those with COVID-19 pneumonia not requiring invasive ventilation. This is a study of 389 patients with COVID-19 pneumonia randomized 2:1 to treatment with tocilizumab versus placebo. All patients were PCR positive and had oxygen saturations of <94% but were excluded if they required CPAP, BiPAP or invasive ventilation. The outcome was death or need for invasive ventilation at day 28. The primary outcome (death + need for invasive ventilation) favored treatment with tocilizumab. However, there was no difference in the rate of death or the median time to clinical improvement. In fact, there was a trend toward worse outcomes in the tocilizumab group (10.4% in the treatment group vs 8.6% in the placebo group). The full study can be found here.
This doesn’t really push us to change the current Infectious Disease Society of America (IDSA) recommendation that tocilizumab not be used routinely in COVID-19.
Salama C et al. Tocilizumab in Patients Hospitalized with Covid-19 Pneumonia N Engl J Med 2021; 384:20-30 DOI: 10.1056/NEJMoa2030340
Week of December 31st, 2020 through January 5th, 2021
Welcome to the McGraw-Hill’s COVID-19 channel. This week we have information on the sensitivity of rapid antigen testing versus PCR testing, new CDC allergy contraindications to being vaccinated, and an update on the more infectious variant of SARS-CoV-2.
If you think they have COVID-19 and the antigen test is discordant with the patient’s symptoms, consider doing a PCR. This is a study of SARS-CoV-2 detection using the Sofia SARS Antigen Fluorescent Immunoassay (FIA) compared to real-time reverse transcription–polymerase chain reaction (RT-PCR) which was considered the gold standard. A total of 1098 paired were tested.
- In those who were asymptomatic (871), the antigen test was 41% sensitive, 98% specific with a positive predictive value of 33% negative predictive value of 99%.
- In those who were symptomatic (227) the antigen test was 80% sensitive with a specificity of 99% and a negative predictive value of 96%.
Antigen testing is a rapid and less expensive alternative for screening for COVID-19. However, compared to the gold-standard RT-PCR, the performance characteristics lag. What does this mean? A positive antigen test in an asymptomatic patient is likely a false positive. Do a PCR. A negative antigen test in a symptomatic patient is likely a false negative. Do a PCR.
If your clinical judgment disagrees with the antigen test, get an RT-PCR on that patient. The full paper can be found here.
- Pray IW, Ford L, Cole D, et al. Performance of an Antigen-Based Test for Asymptomatic and Symptomatic SARS-CoV-2 Testing at Two University Campuses — Wisconsin, September–October 2020. MMWR Morb Mortal Wkly Rep 2021;69:1642–1647. DOI: http://dx.doi.org/10.15585/mmwr.mm695152a3external icon
The FDA has updated the allergy contraindications to the SARS-CoV-2 vaccine (verbatim). "The CDC considers a history of the following to be a contraindication to vaccination with both the Pfizer-BioNTech and Moderna COVID-19 vaccines:
- Severe allergic reaction (e.g., anaphylaxis) after a previous dose of an mRNA COVID-19 vaccine or any of its components
- Immediate allergic reaction of any severity to a previous dose of an mRNA COVID-19 vaccine or any of its components (including polyethylene glycol [PEG])*
- Immediate allergic reaction of any severity to polysorbate (due to potential cross-reactive hypersensitivity with the vaccine ingredient PEG)*
* These persons should not receive mRNA COVID-19 vaccination at this time unless they have been evaluated by an allergist-immunologist and it is determined that the person can safely receive the vaccine (e.g., under observation, in a setting with advanced medical care available)."
Other points of note: The vaccine should be offered regardless of a history of prior symptomatic or asymptomatic infection. Patients who are currently symptomatic can still be vaccinated but it should be deferred until the patient is asymptomatic and safe to leave isolation. A complete discussion of the vaccine indications/contraindications can be found here.
According to NPR reporting, the new, more infectious, SARS-CoV-2 variant has been found in Colorado, California and Florida. The Canadian Broadcast Corporation notes that it has also been found in Canada (Ontario, British Columbia, Alberta and Quebec) as well as South Africa and elsewhere. According to the CDC, there is no evidence that it causes worse disease. There is no anticipated effect of the new UK variant on the effectiveness of any vaccine. Studies are ongoing. A transcript of the CDC press briefing can be found here. There is some concern about the South African variant and current vaccine effectiveness.
Week of December 23rd through December 30th
Welcome to the McGraw-Hill COVID-19 channel. This week we have two studies from separate groups on antibody status after infection and a report from the European CDC on the new COVID variant.
Antibodies from a prior COVID-19 infection are protective for at least 6 months. The first study is of 11,364 health care workers who were anti-spike antibody negative and 1265 who were anti-spike antibody positive (indicating prior infection). Participants had PCR testing at least every 2 weeks and serologic testing every two months. They were followed for “up to 31 weeks”. Two-hundred and twenty-three individuals who were initially antibody negative developed a positive PCR (1.09 per 10,000 patient-days). Only two who were initially antibody positive developed a positive PCR (0.13 per 10,000 patient-days) and both were asymptomatic. The full study can be found here.
This pragmatic study shows a low rate of reinfection after a primary infection. There are some limitations to the data (for example, we cannot standardize exposure to the virus). It is reassuring that both patients who were reinfected were asymptomatic.
Antibody positivity does wane, however. The second study is of 58 individuals who had a previous asymptomatic or mildly symptomatic infection with SARS-CoV-2. They looked at the persistence of anti-SARS-CoV-2 antibodies including anti-spike antibodies as well as antinucleocapsid antibodies at 8 months (32 week). While most patients still had detectable antibody (69%-91% depending on the antibody and assay used), only 53% had neutralizing antibodies.
How can we reconcile these results with those of the first study? First, the participants in the second (much smaller) study had mild or asymptomatic disease. We know that those who have had worse disease have a more robust antibody response. Second, antibody levels, while important, are a surrogate marker for protection. In the pragmatic, real-world, study, prior infection seemed to be protective. We clearly haven’t heard the last word on the question of prolonged immunity.
- Lumley SF, O’Donnell D, Stroesser NE. Antibody Status and Incidence of SARS-CoV-2 Infection in Health Care Workers NEJM December 23, 2020 DOI: 10.1056/NEJMoa2034545
- Choe PG, Kim K-H, Kang CK, Suh HJ, Kang E, Lee SY, et al. Antibody responses 8 months after asymptomatic or mild SARS-CoV-2 infection. Emerg Infect Dis. 2021 Mar [date cited]. https://doi.org/10.3201/eid2703.204543
There is a new, more infectious, variant of SARS-CoV-2 in Britain and elsewhere. Infectivity is increased by up to 70% (increasing the R by 0.4 or more). According to the European CDC, there is no data suggesting that it causes worse disease. Both Moderna and BioNTech believe that their RNA vaccines will continue to be effective against the new variant with the chief executive of BioNTech pointing out in a Reuters’s article that “The vaccine contains more than 1,270 amino acids, and only nine of them are changed (in the mutated virus). That means that 99% of the protein is still the same.” Studies of how the mutation impacts the protection offered by the vaccine are ongoing.
We will update this information as new data becomes available.
- The full statement from the European CDC can be found here.
- An unreviewed, prepublication, version of the infectivity modeling data from the London School of Hygiene and Tropical Medicine can be found here.
- The Reuters’s article can be found here.
Week of December 15th through December 22nd
Welcome to McGraw-Hill’s COVID-19 channel. This week we have information about the emergency use authorization (EUA) for Moderna’s vaccine, information on postmortem stability of the SARS-CoV-2 in nasopharyngeal mucosa, more information on returning to sports following SARS-CoV-2 infection, and information about ivermectin, the latest in a long line of touted “miracle drugs” for COVID-19.
Moderna’s SARS-CoV-2 vaccine has been granted an EUA. In a randomized, placebo-controlled study of 28,207 participants, it was found to be 94% effective when given in two doses 28 days apart. For those over age 65, the efficacy was 86%. The safety data, based on 30,351 individuals revealed “pain at injection site (91.6%), fatigue (68.5%), headache (63.0%), muscle pain (59.6%), joint pain (44.8%), and chills (43.4%)”.1 Information from the EUA (essentially verbatim):2
- The Moderna COVID-19 Vaccine is authorized for use in individuals 18 years of age and older. (contrast this with the Pfizer-BioNTech which has an EUA for those age 16 and older).
- The vaccination provider must communicate to the individual receiving the Moderna COVID-19 Vaccine or their caregiver, information consistent with the “Fact Sheet for Recipients and Caregivers” prior to the individual receiving the Moderna COVID-19 Vaccine. (find the patient information here).
- The vaccination provider must include vaccination information in the state/local jurisdiction’s Immunization Information System (IIS) or other designated system.
- The vaccination provider is responsible for mandatory reporting of the Vaccine Adverse Event Reporting System (https://vaers.hhs.gov/reportevent.html). See here for details of reporting.
- Do not administer the Moderna COVID-19 Vaccine to individuals with a known history of a severe allergic reaction (e.g., anaphylaxis) to any component of the Moderna COVID-19 Vaccine
- There is limited data in pregnancy, lactation and in those immunosuppressed.
- Details of storage and administration can be found in “Factsheet for Healthcare Provider” referenced below.3
- The Full FDA Moderna Briefing Document can be found here.
- The EUA can be found here.
- The Fact Sheet for Healthcare Providers can be found here.
- The Fact Sheet for Recipients and Caregivers can be found here.
The SARS-CoV-2 virus is stable in nasopharyngeal mucosa for at least 7 days postmortem. This study from the CDC journal “Emerging Infections Diseases” reports on viral persistence over 7 days in a study of 11 individuals who died with COVID-19. Sequential nasopharyngeal swabs were taken between 0 and 168 hours. All samples were positive for the SARS-CoV-2 virus with no decrement in the number of viral particles. A separate study showed replicating virus 36 hours after death. The full study can be found here.
The WHO has released guidelines on managing those deceased from COVID-19. These guidelines, available in several languages, can be found here.
- Heinrich F, Meißner K, Langenwalder F, Püschel K, Nörz D, Hoffmann A, et al. Postmortem stability of SARS-CoV-2 in nasopharyngeal mucosa. Emerg Infect Dis. 2021 Jan. https://doi.org/10.3201/eid2701.203112
- Infection prevention and control for the safe management of a dead body in the context of COVID-19: interim guidance, 4 September 2020 https://apps.who.int/iris/handle/10665/334156
Kaiser Permanente Sports Medicine has published a handbook on return to sports after COVID-19. It includes suggestions for graded return to sports as well as specific exercises that one can do depending on what sport they participate in. They note that:
- Intense exercise has been associated with an increased risk of contracting COVID-19.
- In some studies, 1 in 5 hospitalized patients with COVID-19 had some evidence of heart muscle damage and that the long-term effects of this are unknown.
- A cardiologist should be involved in return to sports decisions for those athletes who were hospitalized with “severe” COVID-19 symptoms.
- It may take 3-6 months for those with myocarditis to return to training.
Other information includes information on athlete wellness, nutrition, infection prevention, specific exercises that can be done to maintain strength for specific sports, sleep suggestions, etc. There are numerous links throughout the document for the provider and/or athlete on wellness, etc. The full document can be found here.
- Kaiser Permanente. Return to Sports Playbook, October 5, 2020. Available at: https://permanente.org/wp-content/uploads/2020/10/KP-COVID-Return-to-Sports-Playbook-PM.pdf
Ivermectin is associated with reduced mortality in COVID-19. This is a retrospective cohort study of 280 consecutively admitted patients at four Florida hospitals with severe COVID-19 treated with ivermectin or not.1 The treatment group got at least one dose of ivermectin followed by a second dose 7 days later, both at the discretion of the treating team. Most patients were also treated with hydroxychloroquine and/or azithromycin. The outcome was all-cause in hospital mortality.
They used logistic regression and a propensity scoring to adjust the data for underlying illnesses, gender, hypertension, etc. After controlling for other confounders, there was an 11.2% reduction in mortality in the ivermectin group (NNT = 8.9 with CI95% 4.5-263).
This is a promising study of ivermectin. Note that the CI for the NNT is as high as 263 (though also as low as 4.5). While promising, the authors note that, “Further studies in appropriately randomized trials are recommended before any conclusions can be made.” The full “Chest” study can be found here.
The current recommendation from the NIH treatment guidelines is that “The COVID-19 Treatment Guidelines Panel recommends against the use of ivermectin for the treatment of COVID-19, except in a clinical trial (AIII).2
- 1. Cepelowicz-Rajter J, Sherman MS, et. al. Use of Ivermectin Is Associated With Lower Mortality in Hospitalized Patients With Coronavirus Disease 2019 The ICON Study, Chest. October 12, 2020 DOI:https://doi.org/10.1016/j.chest.2020.10.009
Week of December 10th through December 14th
Welcome to the McGraw-Hill COVID-19 channel. This week we have news about the long- awaited Pfizer-BioNTech vaccine for COVID-19 and the Emergency Use Authorization (EUA) for baricitinib.
The FDA approved an EUA for the Pfizer-BioNTech COVID-19 vaccine on 11 December 2020. Some of the critical points are (verbatim):
- “Pfizer-BioNTech COVID-19 Vaccine is authorized for use in individuals 16 years of age and older.
- The vaccination provider must communicate to the individual receiving the Pfizer-BioNTech COVID-19 Vaccine or their caregiver, information consistent with the “Fact Sheet for Recipients and Caregivers” prior to the individual receiving Pfizer-BioNTech COVID-19 Vaccine. This document can be found here.
- The vaccination provider must include vaccination information in the state/local jurisdiction’s Immunization Information System (IIS) or other designated system.”
- The vaccination provider is responsible for mandatory reporting of the following to the Vaccine Adverse Event Reporting System (VAERS), including errors, adverse events, cases of Multisystem Inflammatory Syndrome (MIS) and any subsequent cases of COVID-19 leading to a hospital stay or death.
There have been two cases of non-fatal anaphylaxis in Britain but no deaths. In Phase III trials, one of the 18,801 participants who received the vaccine had an anaphylactic reaction, but patients who had a history of vaccine-related anaphylaxis were excluded from the initial trials. These reactions have led to a recommendation in the UK, but not in the US, that anyone needing to carry an epinephrine pen for a prior allergy be excluded from vaccination until further information is available.
The US recommendation per the FDA is “Do not administer Pfizer-BioNTech COVID-19 Vaccine to individuals with known history of a severe allergic reaction (e.g., anaphylaxis) to any component of the Pfizer-BioNTech COVID-19 Vaccine’. However, every administration site must be equipped to handle acute anaphylaxis.
Remember to continue to recommend mask and social distancing measures. The 95% effectiveness rate is for day 7 after the second dose of the vaccine (e.g. day 28) plus social distancing.
- The EUA can be found here.
- The patient information sheet can be found here.
- The provider information sheet can be found here. It includes information on storage, dilution, administration, etc.
- The Pfizer-BioNTech FDA submission can be found here.
The FDA has issued an EUA for baricitinib, an immunomodulator, for use in COVID-19. Baricitinib is an oral Janus kinase (JAK) enzyme inhibitor that is approved for use in conjunction with remdesivir for hospitalized patients over the age of two with COVID-19 who are on oxygen, being ventilated or who are on ECHMO. It is not recommended in those with active tuberculosis, ESRD on dialysis, or with a GFR of <15 ml/min/1.73m3. It seems to reduce recovery time by one day when added to remdesivir. However, it is unknown if it adds anything to dexamethasone. The EUA can be found here.
The lack of press fanfare helps to put baricitinib in perspective. The data is weak, it can only be used with remdesivir, and we don’t know if it adds anything to dexamethasone.
- The fact sheet for providers can be found here.
- The fact sheet for patients can be found here.
- The EUA can be found here.
Week of December 5th through December 9th
Welcome to the McGraw-Hill COVID-19 channel. This week we have updated guidance from the American Academy of Pediatrics (AAP) on return to sports, new information on the “real world” sensitivity and specificity of COVID antibody tests, and caution from the FDA about patients wearing masks containing metal while getting an MRI. Finally, the Infectious Disease Society of America (ISDA) has released updated guidelines on prevention, diagnostics, the use of serology, and treatment of COVID-19.
The AAP has released new recommendations for returning to sports after having COVID-19. This December 4th update includes the following:
- Face coverings should be worn even during competition, with the exception of individual outdoor sports (single’s tennis, golf). Other exceptions include swimming/diving/water sports, and cheerleading/gymnastics because of the risk the mask may get caught on apparatus and be a choking risk.
- Individuals should not participate in sports if someone in the family is symptomatic.
- Mildly symptomatic children (<4 days of fever, minimal myalgias, chills and lethargy) should be cleared by their provider before returning to sports.
- Moderately symptomatic children (>4 days of fever >100.4°F, myalgia, chills, or lethargy or those who had a non-ICU hospital stay and no evidence of MIS-C) should have an ECG and a cardiology consult is recommended. Workup may include cardiac MRI, echocardiogram, etc.
- Those with severe disease (ICU, intubation, MIS-C) should be seen by cardiology prior to discharge from the hospital and should have “extensive cardiac testing”
They also recommend the following roadmap (verbatim, adapted from Elliott N, et al, infographic, British Journal of Sports Medicine, 2020). It assumes that patients are asymptomatic, and it has been at least 10 days since the onset of symptoms.
- Stage 1: Day 1 and Day 2 - (2 Days Minimum) - 15 minutes or less: Light activity (walking, jogging, stationary bike), intensity no greater than 70% of maximum heart rate. NO resistance training
- Stage 2: Day 3 - (1 Day Minimum) - 30 minutes or less: Add simple movement activities (e.g. running drills) - intensity no greater than 80% of maximum heart rate
- Stage 3: Day 4 - (1 Day Minimum) - 45 minutes or less- Progress to more complex training - intensity no greater than 80% maximum heart rate. May add light resistance training
- Stage 4: Day 5 and Day 6 - (2 Days Minimum) - 60 minutes -Normal training activity - intensity no greater than 80% maximum heart rate
- Stage 5: Day 7 - Return to full activity/participation (ie, - Contests/competitions)“
- American Academy of Pediatrics. COVID-19 Interim Guidance: Return to Sports. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/
The Infectious Disease Society of America (ISDA) has released updated guidelines on management and treatment of COVID-19. Among the key recommendations are:
- Lopinavir/ritonavir: Recommend against
- Dexamethasone: Recommend for critically ill and “severe” patients hospitalized with COVID-19
- Tocilizumab: Data is lacking but conditional recommendation against.
- Convalescent plasma: Should be used only in the setting of a trial (see our discussion of negative studies here)
- Remdesivir: five days is recommended for those needing supplemental oxygen (conditional recommendation) and for 10 days for those on mechanical ventilation or ECMO (conditional recommendation). Remdesivir should not be used for those with an oxygen saturation of >94% on room air (conditional recommendation).
The IDSA recommendations are available for free as an app for both Apple (search app store for “IDSA guidelines”) and Android. The app contains not only COVID-19 guidelines but guidelines for many other infectious diseases. The online document can be found here.
- Infectious Disease Society of America Guidelines on the Treatment and Management of Patients with COVID-19 https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/
More evidence that providers should not be reliant on antibody tests to make the diagnosis of COVID-19. This is a study comparing a rapid antibody test for SARS-CoV-2 to the gold standard in 2847 front line works (268 known to be PCR positive for SARS-CoV-2), and 1995 control samples taken before the pandemic (and thus presumed to be SARS-CoV-2 negative). The gold standard was a highly accurate measure of antibodies against the N-protein (Roche Elecsys anti-nucleoprotein assay). Overall, sensitivity of the antibody test was 94% among those who were PCR positive, but only 85% in those who were not PCR positive. This reflects lower antibody titers among those who did not have a history of significant clinical COVID-19 (e.g. were mildly symptomatic or asymptomatic; only 62% of those with antibodies reported symptoms). Specificity was 98% in those who were known negatives. They calculate that if the incidence in the population is 10%, around one in five positive tests would be false positive.
This confirms what we already know: rapid antibody tests should not be relied upon to make the diagnosis of COVID-19. This is consistent with the IDSA recommendations, a link to which can be found above. The weakness of this trial is that they tested only one rapid antibody assay and we are assuming the “gold standard” is correct. The complete paper can be found here.
- Mulchandani R, Jones HE et al. , Accuracy of UK Rapid Test Consortium (UK-RTC) “AbC-19 Rapid Test” for detection of previous SARS-CoV-2 infection in key workers: test accuracy studyBMJ 2020; 371 :m4262
The FDA issued a reminder to use metal-free masks during MRI. Besides the obvious metal nose pieces, they warn about masks with metal nanoparticles or antimicrobial silver and copper coatings. The full statement can be found here.
- FDA Safety Communication: Wear Face Masks with No Metal During MRI Exams. https://www.fda.gov/medical-devices/safety-communications/wear-face-masks-no-metal-during-mri-exams-fda-safety-communication
Week of December 1st through December 4th
Welcome to the McGraw-Hill COVID-19 channel. This week we have new information on the length of quarantine following exposure, a negative study of convalescent plasma, along with updated FDA guidelines on convalescent plasma. Finally, we have a real word report on the batch testing of COVID-19 RT-PCR samples.
The CDC has reduced the length of time one needs to quarantine after exposure to COVID-19 from 14 days to 7-10 days. They recommend the following two strategies “depending on local circumstances and resources” (verbatim):
- “Quarantine can end after Day 10 without testing and if no symptoms have been reported during daily monitoring. With this strategy, residual post-quarantine transmission risk is estimated to be about with an upper limit of about 10%.
- When diagnostic testing resources are sufficient and available then quarantine can end after Day 7 if a diagnostic specimen tests negative, and if no symptoms were reported during daily monitoring. The specimen may be collected and tested within 48 hours before the time of planned quarantine discontinuation (e.g., in anticipation of testing delays), but quarantine cannot be discontinued earlier than after Day 7. With this strategy, the residual post-quarantine transmission risk is estimated to be about 5% with an upper limit of about 12%.
- In both cases, additional criteria (e.g., continued symptom monitoring and masking through Day 14) must be met and are outlined in the full text.”
Elsewhere in the document, it is mentioned that “adding testing at entry to quarantine provided little additional benefit in terms of reduction in post-quarantine transmission risk.”
There is a balance here. It is hoped that reducing the number of days of quarantine will increase quarantine compliance without a net increase in transmission. While 14 days is still the safest option, the CDC points out that many people do not complete the quarantine and may be hesitant to report contacts because of the burden of a 14-day quarantine. It is noted that “while a shorter quarantine substantially reduces secondary transmission risk, there may be settings (e.g., with high contact rates) where even a small risk of post-quarantine transmission could still result in substantial secondary clusters.” The full document can be found here.
- Options to Reduce Quarantine for Contacts of Persons with SARS-CoV-2 Infection Using Symptom Monitoring and Diagnostic Testing https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-options-to-reduce-quarantine.html December 2nd 2020
Convalescent plasma is ineffective at treating “severe” COVID-19.1 This is a randomized, double blind, placebo control trial of convalescent plasma (228 active drug, 105 placebo). All patients were TR-PCR positive for SARS-CoV-2, had COVID-19 related pneumonia and were “severe”, defined by oxygen saturation below 93% on room air, an PaO2/FiO2 below 300 (normal is > 400-500) or a SOFA score more than 2 above the patient’s baseline. Importantly, the titers of convalescent antibodies being given were measured with a median titer of 1:3200. There was no difference in outcomes between the groups. Mortality was 11% in the convalescent plasma group and 11.4% in the placebo group. Adverse outcomes were the same between groups. The full study can be found here.
This is consistent with a prior study that showed no benefit to convalescent plasma2
- Simonovich, VA et al. A randomized Trial of Convalescent plasma in COVID-19 Severe Pneumonia NEJM November 24, 2020 DOI: 10.1056/NEJMoa2031304
- Agrawal, A et al. Convalescent plasma in the management of moderate COVID-19 in adults in India: open label phase II multicentre randomised controlled trial (PLACID Trial) BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m3939
The FDA updated guidelines for the Emergency Use Authorization (EUA) of convalescent plasma on November 16th. Some of the salient points taken from the documents include:
- “Convalescent plasma should not be considered a new standard of care for the treatment of patients with COVID-19.”
- Patients must be made aware that the risks and benefits are unknown.
- Keep records and investigate any adverse reactions. Fatalities must be reported to the FDA.
Previous studies have shown convalescent plasma to be safe; however, as noted above, efficacy is questionable.
- The updated November 16th “Recommendations for Investigational COVID-19 Convalescent Plasma” can be found here
- The Emergency Use Authorization information can be found here
- Information on the collection and storage of convalescent plasma can be found here.
Pooled testing showed benefits in the real world. This an MMWR report of Duke University’s experience with pooled testing (multiple samples are combined and tested together with individual follow-up testing of any batch noted to be positive). Pooled batches of 68,913 specimens were tested. Eighty-four positives were identified, of whom 51% were asymptomatic.
Aggressive contract tracing, quarantine and isolation were included in the protocol. This strategy reduced reagent use by about 80% and allowed the university to stay open for in-person instruction for 10 weeks; no cases of in-classroom transmission were found.
They point out that the exact numbers and effectiveness is partly based on the prevalence of disease in the community. Additionally, they had a well-defined cohort. However, at least in a structured environment with a low prevalence of disease, batch testing is effective. The complete article can be found here.
- Denny TN, Andrews L, Bonsignori M, et al. Implementation of a Pooled Surveillance Testing Program for Asymptomatic SARS-CoV-2 Infections on a College Campus — Duke University, Durham, North Carolina, August 2–October 11, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1743–1747. DOI: http://dx.doi.org/10.15585/mmwr.mm6946e1
Week of November 17th through November 30th
Welcome to the McGraw-Hill COVID-19 channel. We hope that everyone had a good Thanksgiving. It has been a pretty busy week in COVID-19 news. This week we have information on the approval of Regeneron's monoclonal antibody, more information on the effectiveness of masks, several negative studies of hydroxychloroquine for prophylaxis and treatment, and a JAMA review article on anticoagulation in COVID-19.
The first paper reviews the state-of-the-art regarding anticoagulation in COVID-19 patients. The authors point out that thromboembolic disease occurs in up to 36% of patients hospitalized with severe COVID-19. This is likely the result of prothrombotic abnormalities, including decreased levels of protein C and protein S (and, see here for our discussion about anticardiolipin antibodies in COVID-19). While this is still an evolving field, they point out that:
- Both the American College of Chest Physicians (ACCP) and the International Society on Thrombosis and Hemostasis (ISTH)) suggest prophylaxis with low molecular weight heparin (LMWH) or fondaparinux for all hospitalized COVID-19 patients unless there are contraindications (e.g. bleeding).
- Per the International Society on Thrombosis and Haemostasis (ISTH): Half-dose LMWH is reasonable if the patient has a high bleeding risk. If the patient is obese, consider increasing the dose of LMWH by 50%.
- There remains a lack of good data on full dose LMWH as prophylaxis.
- The American College of Clinical Pharmacy (ACCP) does not recommend post-discharge DVT prophylaxis while the ISTH suggests it is reasonable if clot risk is high and bleeding risk is low (see HAS-BLED score, for example).
- Surveillance ultrasonography for asymptomatic thromboembolic disease is not recommended.
- Treatment of thromboembolic disease should follow the usual guidelines.
This paper is free and can be found here. It is short, to-the-point, and worth downloading if you are caring for COVID-19 patients.
- Piazza G, Morrow DA. Diagnosis, Management, and Pathophysiology of Arterial and Venous Thrombosis in COVID-19. JAMA. Published online November 23, 2020. doi:10.1001/jama.2020.23422
The FDA has issued an emergency use authorization (EUA) for Regeneron’s monoclonal antibody cocktail in those with mild disease who are at least 12 years old and weigh at least 40kg. It is not authorized for inpatients or those who require oxygen and “may be associated with worse clinical outcomes” in those patients. Casirivimab and imdevimab are given together and reduce disease progression in high-risk patients. The EUA can be found here. Some categories of high-risk patients are those who (verbatim from the FDA):
- Have a body mass index (BMI) ≥35
• Have chronic kidney disease
• Have diabetes
• Have immunosuppressive disease
• Are currently receiving immunosuppressive treatment • Are ≥ 65 years of age
- Are ≥ 55 years of age, AND have:
o cardiovascular disease, OR
o hypertension, OR
o chronic obstructive pulmonary disease/other chronic respiratory disease
A full list of high-risk criteria can be found here. (The document itself is about Bamlanivimab but it lists the FDA high-risk criteria).
More negative studies of hydroxychloroquine, the first when used as post-exposure prophylaxis, and the other when used as therapy.
The first study is a randomized trial of 2314 asymptomatic individuals exposed to 672 index cases of COVID-19. Participants were randomized to hydroxychloroquine or placebo. The outcome was symptomatic, PCR positive, disease. Approximately 13% of each group were PCR positive at baseline, but had no symptoms, and were followed for progression of symptoms.
There were no differences in infection rates between the two groups, and hydroxychloroquine did not prevent progression to symptomatic disease in those who were PCR positive at baseline. Adverse events were much more common in the hydroxychloroquine group (56% versus 6% though none were serious).
This is yet another study that shows hydroxychloroquine does not prevent infection nor progression to symptomatic disease. The small number of patients in the “already positive” group cannot give us a definitive answer, but it is consistent with other studies that have shown no benefit in early COVID-19. The full study can be found here.
The second study is the long-awaited results of the hydroxychloroquine arm of the RECOVERY trial. This was an open label, randomized study of 667 patients with COVID-19 divided into three groups: Usual care, usual care plus hydroxychloroquine, or usual care with hydroxychloroquine plus azithromycin. All patients were hospitalized but required less than four liters of oxygen by nasal cannula, or less than 40% oxygen by venturi mask (i.e. they had mild to moderate disease). The outcome was clinical status at 15 days on a seven-point scale. The modified intention-to-treat analysis only included those with proven COVID-19 by rPCR (504 patients). There was no difference on the seven-point scale between the groups. Once again hydroxychloroquine was ineffective. The full study can be found here.
Why did we choose to cover yet more negative hydroxychloroquine studies? We are still hearing from patients and patient families that people are dying unnecessarily of COVID-19 because hydroxychloroquine is not being used in the US (and elsewhere). The more information you have in your armamentarium to counteract these fallacies, the better.
· Mitja O, Corbacho-Monne M, et al. A Cluster-Randomized Trial of Hydroxychloroquine for Prevention of Covid-19. NEJM November 24, 2020 DOI: 10.1056/NEJMoa2021801
· Cavalcanti AB, Zapierir FG, et. al. Hydroxychloroquine with or without Azithromycin in Mild-to-Moderate Covid-19 N Engl J Med 2020; 383:2041-2052 DOI: 10.1056/NEJMoa2019014
· Self WH, Semler MW, Leither LM, et al. Effect of Hydroxychloroquine on Clinical Status at 14 Days in Hospitalized Patients With COVID-19: A Randomized Clinical Trial. JAMA. Published online November 09, 2020. doi:10.1001/jama.2020.22240 (not reviewed above but also negative).
A real-word trial by the CDC of mask-by-use in Kansas state counties shows those with a mask mandate had a six percent decrease in COVID-19 cases, while those not mandating masks had a 100% increase in COVID-19 cases. The full trial can be found here.1
Why are we including this? A randomized study2 found no decrease in cases with mask wearing and has been cited by various “anti-mask” groups as proof that masks don’t work. However, only 50% of participants were randomized to wear masks, and there was variable compliance (only 46% wore the masks as instructed). In addition, masks were used by less than five percent of the population, allowing for ample exposure to, and spread of, the virus. The real-world data belter reflects what we can accomplish with a simple mask mandate: a reduction of spread.
- Van Dyke ME, Rogers TM, Pevzner E, et al. Trends in County-Level COVID-19 Incidence in Counties With and Without a Mask Mandate — Kansas, June 1–August 23, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1777-1781. DOI: http://dx.doi.org/10.15585/mmwr.mm6947e2
- Bundgaard JS, Raaschou-Pedersen DET, et al. Effectiveness of Adding a Mask Recommendation to Other Public Health Measures to Prevent SARS-CoV-2 Infection in Danish Mask Wearers: A Randomized Controlled Trial. Annals of Internal Medicine 0;0 [Epub ahead of print 18 November 2020].doi:https://doi.org/10.7326/M20-6817
Week of November 12th through November 17th
Welcome to the AccessMedicine COVID-19 channel. This week we have a study examining the risk of disease progression in patients randomized to fluvoxamine versus placebo, information about autoantibodies to Interferon-γ (IFN-γ) in patients with severe COVID-19, and new mask recommendations from the CDC.
Fluvoxamine was associated with a reduced risk of progression of COVID-19 in outpatients with mild disease. This is a double-blind, study of 152 outpatients (72% women, average age 46) randomized to fluvoxamine (100mg TID for 15 days) or placebo within seven days of onset of their symptoms. Patients had to have an oxygen saturation of 92% or greater at the onset of the study, be community dwelling and with a confirmed diagnosis of COVID-19. The outcomes included “shortness of breath or hospitalization for shortness of breath or pneumonia, and oxygen saturation of <92%, or need for supplemental oxygen to maintain an oxygen saturation of 92% or greater.”
Twenty-four percent of enrollees did not complete the trial. Zero of 80 patients in the fluvoxamine group met the criteria for clinical deterioration versus six of 72 in the placebo group; four of the six were hospitalized. The NNT was 11.
As with most studies, there are caveats. First, only 13.5% of the patients screened were included in the study. This does not mean that fluvoxamine was not useful in the group studied, only that the applicability cannot be generalized to “all comers”. Additionally, this was a relatively young population and 72% were women (who tend to have better outcomes as a group than do men). As pointed out by the authors, this data should be treated as preliminary and should prompt a larger study.
Why fluvoxamine? It targets the σ-1 receptor (S1R) which modulates the immune response. Fluvoxamine has been shown to reduce the inflammatory response in animal models of sepsis.
- Lenze EJ, Mattar C, Zorumski CF, et al. Fluvoxamine vs Placebo and Clinical Deterioration in Outpatients With Symptomatic COVID-19: A Randomized Clinical Trial. JAMA. Published online November 12, 2020. doi:10.1001/jama.2020.22760
The CDC has updated information about mask use to reflect data that masks protect the wearer. One of the reasons given for not wearing a mask has been that the mask does not protect the wearer. The CDC points out that multiple layers of cloth can reduce inhaled particles by 50%. For those interested, they present a summary of the data of “real world effectiveness” of mask wearing in preventing SARS-CoV-2 transmission. They recommend multi-layer cloth masks without valves The full article can be found here.
Autoantibodies to immune mediators are found in at least some patients sick with COVID-19. Last week we reported on a paper that found anticardiolipin antibodies in patients with COVID-19. This is a report of the presence of autoantibodies that impair type I interferons in 987 patients hospitalized with severe COVID-19, 663 mildly symptomatic or asymptomatic patients with COVID-19 and in 1227 healthy controls. They found IgG autoantibodies against interferon-γ (IFN-γ) in 10.2% of those with COVID-19 pneumonia versus zero percent in those with mild or asymptomatic disease (2.6% of women, 12.5% of men). These antibodies seem to be genetically determined rather than a specific response to SARS-CoV-2. They hypothesize that the absence of functioning IFN-γ causes an immunodeficient state leading to worse COVID-19 outcomes.
According to the authors, this explains at least some of the predominance of severe disease in men. They suggest therapies such as plasmapheresis or autoantibody-resistant recombinant Type I interferons as possible useful therapies in the future. The full paper can be found here.
- Bastard et al., Autoantibodies against type I IFNs in patients with life-threatening COVID-19. Science Oct 2020;6515. eabd4585
Week of November 3rd through November 11th
Welcome to the McGraw-Hill COVID-19 channel. This week we have an update on COVID-19 related autoantibodies, information about the culling of mink in Denmark secondary to COVID-19, the announcement of the first test specific for neutralizing antibodies, an emergency use authorization for the first monoclonal antibody in outpatients and an FDA announcement about false positive tests when using rapid detection.
COVID-19 related autoantibodies include prothrombotic antiphospholipid antibodies, anticardiolipin antibodies (aPL), and other prothrombotic antibodies. COVID-19 is associated with the presence of autoantibodies (e.g. a positive ANA1) as well as with prothrombotic events. This study answers the question of whether these two findings are related. This study2 measured levels of eight antiphospholipid antibodies in 172 patients hospitalized with COVID-19. Antiphospholipid antibodies were found in 52% of samples. These were more common in patients with severe lung and renal disease.
In the second part of the study they injected purified IgG antiphospholipid antibodies from patients into mice and noted accelerated venous thrombosis. This suggests that aPL antibodies play a role in the prothrombotic state of many patients with COVID-19.
It is hard to know how to apply this data to our patients, but it is does clarify the nature of at least some of the autoantibodies found in COVID-19 patients. The full study can be found here.
1) Matthew C, Woodruff RP, Ramonsell F. et al. Clinically identifiable autoreactivity is common in severe SARS-CoV-2 Infection medRxiv 2020.10.21.20216192; doi: https://doi.org/10.1101/2020.10.21.20216192 (Prepublication)
2) Zuo Y, Estes SK, Ramadan AA, et al. Prothrombotic autoantibodies in serum from patients hospitalized with COVID-19. Science Translational Medicine 02 Nov 2020: eabd3876 DOI: 10.1126/scitranslmed.abd3876
The FDA is warning about false positive tests for SARS-CoV-2 when using rapid antigen detection. The key points are:
- False positives are expected, especially when testing populations with a low pre-test probability." Consider positive results in combination with clinical observations, patient history, and epidemiological information.”
- In nursing homes and other high-risk situations, consider RT-PCR if the patient is found to be negative. These recommendations can be found here.
- Make sure to follow manufacturer’s instructions as each has slightly different specimen handling requirements, etc.
This is worthwhile reading for those using the rapid antigen tests. One may also consider RT-PCR testing to confirm positive tests, especially if in a low prevalence area. This has implications for quarantine, isolation and contact tracing. This will help alleviate chasing false positives.
The first test for neutralizing antibodies has been approved by the FDA. This has implications for the use of convalescent plasma, which can now be tested for viral suppressing antibodies. It also has implications for post-infectious testing to test the duration of an effective immune response.
The FDA points out that this does not suggest that patients use the test results to “stop taking steps to protect themselves and others, such as stopping social distancing, discontinuing wearing masks or returning to work. Remember that antibody tests are not to be used to rule in or rule out active infection. RT-PCR is still the standard. The full statement can be found here.
The first monoclonal antibody has gotten emergency use authorization (EUA) for treating mild to moderate COVID-19 patients but is not indicated in hospitalized patients. Bamlanivimab is approved in COVID-19 test positive patients over age 12, over 40kg and who are high risk of worsening disease. These include patients over 65 years old, obesity, diabetes, COPD and other conditions that predispose to worse outcomes. It is for outpatient use only and is not approved for patients who require oxygen. These sicker patients seem to have worse outcomes when treated with Bamlanivimab.
The full FDA announcement can be found here. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-monoclonal-antibody-treatment-covid-19
Briefly, minks are being culled in Denmark because of unique spike proteins associated with transmission from mink to humans (214 cases of transmission total, 12 with unique spike proteins). The WHO notes that many of the vaccines are dependent on a stable spike protein as a target, thus preventing mutations from developing, such as occurs with mink-to-human transmission. So far as we know, this type of transmission/mutation does not occur in dogs or cats. The WHO statement can be found here.
Week of October 28th through November 2nd
Welcome to the McGraw-Hill COVID-19 channel. This week we have new information on household spread, a negative trial of monoclonal antibodies in patients sick with COVID-19, and another negative trial of tocilizumab in hospitalized patients with COVID-19.
Transmission rates within households for COVID-19 are about 50%. This is a study done between April and September of 101 index cases and 191 household contacts in the US. Participants kept a symptom diary and had SARS-CoV-2 testing sequentially for 14-days. Overall, 53% of household contacts (95% CI 46%-60%) converted to SARS-CoV-2 positive. When broken down by age, the CI for all groups overlapped, indicating transmission within the household regardless of the age of the index case. Seventy-five percent of the cases were transmitted within the first 5 days.
This more rigorous study stands in contrast to earlier studies suggesting a 12% transmission rate within families. The increased risk of transmission noted here could be due to more sensitive testing and more robust screening done over 14 days. This study is ongoing. The full study can be found here.
- Grijalva CG, Rolfes MA, Zhu Y, et al. Transmission of SARS-COV-2 Infections in Households — Tennessee and Wisconsin, April–September 2020. MMWR Morb Mortal Wkly Rep. ePub: 30 October 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6944e1external icon.
Regeneron has shut down enrollment in a study of monoclonal antibodies (MCAs) in COVID-19 patients with high oxygen requirements. The independent data monitoring committee of the REGN-COV2 trial recommended suspending enrollment of those patients on high flow oxygen and mechanical ventilation due to safety concerns. They are continuing to enroll outpatients and inpatients with no or low flow oxygen requirements.
You may be aware that the press has been touting “viral clearance” as a marker for the success of MCAs. However, that is a surrogate outcome. The primary driver for success should be clinical outcomes. And in the sickest patients, there is at least a signal that Regeneron MCAs worsen outcomes.
A separate press release suggests that in 799 patients Regeneron’s MCAs reduced COVID-19 related medical visits (2.8% vs. 6.5%, NNT 43 to reduce 1 COVID-19 related visit). We don’t know if it reduces hospitalizations, oxygen need, etc. Hopefully more data will be forthcoming.
- Regeneron press release about the enrollment of ill patients can be found here.
- Regeneron press release about overall results can be found here.
A second phase II study of monoclonal antibodies showed that 1 of 3 doses reduced circulating viral levels. This is a study of outpatients using 3 different doses of a monoclonal antibody (LY-CoV555) in 309 active patients and 143 placebo patients. 80% of patients had only mild symptoms. The doses used (700 mg, 2800 mg and 70000 mg) were 10 times higher than what the maker predicted would be effective. The primary outcome was a reduction in viral RNA. The 700 mg and 7000 mg doses did not reduce viral load when compared to placebo, but the 2800 mg dose did. In. a secondary endpoint, 6.3% of those who received placebo were hospitalized or had an ED visit versus 1.6% of those who got active drug (NNT=25).
This is somewhat of a mixed bag in regard to results. If there is a dose-response curve, one wouldn’t expect7000mg to be ineffective while 2800mg was effective. Additionally, these doses were 10 times higher than what the study authors predicted would be useful. Even without antibody treatment, only 1 patient needed ICU care and all of the patients had mild symptoms at baseline. This study cannot address the question we really want to know: How does this drug perform in sick patients who need acute treatment? The full study can be found here.
- Chen P, Nirula A, Heller B. et al. SARS-CoV-2 Neutralizing Antibody LY-CoV555 in Outpatients with Covid-19 NEJM October 28th, 2020 DOI: 10.1056/NEJMoa2029849
Tocilizumab, a monoclonal antibody against the interleukin-6 receptor (IL-6R), was not effective in patients hospitalized with COVID-19. This study randomized 243 patients hospitalized with COVID-19 and at least two of the following: Temperature >38oC, pulmonary infiltrates, the need for oxygen to keep the saturation above 92% to either usual care plus tocilizumab (161 patients) or usual care (81 patients). The primary outcome was death or intubation. There was no difference in the primary outcome between the tocilizumab and placebo groups (HR 0.83 (95% CI 0.38-1.81, p =0.4). There was also no benefit in time to discontinuation of oxygen. The full study can be found here. So far, the best tocilizumab studies have been negative.
This is consistent with data suggesting the cytokine storm is not necessarily the end event in COVID-19 any more than it is in similar condition (sepsis, etc.). Targeting cytokines may not be as fruitful as we would like. The cytokine study can be found here.
- Stone JH, Frigault, MJ. Serling-Boyd NJ et al. Efficacy of Tocilizumab in Patients Hospitalized with Covid-19. NEJM October 21st, 2020 DOI: 10.1056/NEJMoa2028836
- Kox M, Waalders NJB, Kooistra EJ, Gerretsen J, Pickkers P. Cytokine Levels in Critically Ill Patients With COVID-19 and Other Conditions. JAMA. Published online September 03, 2020. doi:10.1001/jama.2020.17052
Week of October 21st through October 27th
Welcome to the McGraw-Hill COVID-19 channel. This week we have a negative study of the use of convalescent serum in those with moderate COVID-19, a reassuring report of intubation and aerosolization, and a new definition of “close contact” by the CDC.
Intuitively, intubation is considered a high-risk procedure for aerosolization and SARS-CoV-2 transmission. This study refutes this assumption. This was a three-week study measuring aerosol production during intubation and extubation in operating rooms equipped with “ultraclean, laminal flow ventilation systems…. with HEPA filters.” The measuring device (using laser scatter to determine levels of aerosol) was placed 0.5 meters away from the intubation/extubations and angled towards the patient. Control trials were conducted to ensure that the system was able to measure an increase in airborne particles after a cough. Aerosol production was measured during 19 intubations and 14 extubations. The results indicated that a volitional cough produces more aerosolized particles than does an intubation or extubation procedure.
This information adds to the body of knowledge, but does not necessitate a change to current practice. Extubation is often associated with a cajoling to cough (albeit, this cough generated a smaller aerosol burden). Plus, this study was not done in patients who were already coughing from COVID-19. An aerosolization risk exists even pre-intubation, which still necessitates the wearing of PPE.
- Brown J et al. A quantitative evaluation of aerosol generation during tracheal intubation and extubation. Anaesthesia 2020 Oct 6; [e-pub]. (https://doi.org/10.1111/anae.15292)
Next is a negative study of convalescent serum for treating moderate COVID-19. Even with the results of this study, we still don’t have adeqiate data about the benefit (or lack thereof) of convalescent serum. This is an open label, phase II, study of 464 adults admitted to 49 tertiary care hospitals who had a positive test for COVID-19 and were moderately ill (oxygen saturation 93% or less on room air plus a respiratory rate of >24/minute or a PaO2/FiO2 between 200mm-300mm Hg (normal is 300mm-500mm with 300mm or less indicating impaired gas exchange). Patients were randomized to usual care (229) or two doses of 200ml of convalescent plasma (235). The outcomes included progression to severe disease and death. There was no difference in the combination of progression to severe disease and death at 28 days.
Although negative, there are several limitations to this study that effect its generalizability. Most importantly, titers for SARS-CoV-2 antibodies were not available for the great majority of the infused plasma treatments. And, “standard care” included the discredited treatments hydroxychloroquine, azithromycin. So we again have data that doesn’t allow us to make a firm conclusion. The complete study can be found here.
- Agarwal Anup, Mukherjee Aparna, Kumar Gunjan, Chatterjee Pranab, Bhatnagar Tarun, Malhotra Pankaj et al. Convalescent plasma in the management of moderate covid-19 in adults in India: open label phase II multicentre randomised controlled trial (PLACID Trial) BMJ 2020; 371 :m3939
The CDC has changed the definition of “close contact” to include the cumulative 24-hour exposure to a positive case. The current definition of “close contact” for purposes of quarantine or testing include: “Someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period starting from two days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated.”
This better reflects cumulative exposure risk as opposed to the prior criteria that required a continuous 15-minute exposure. The complete definition can be found here.
Week of October 14th through October 20th
Welcome to the AccessMedicine COVID-19 channel. This week we have information on the transmission of SARS-CoV-2 to pets, new recommendations on mask use on public transport, and a commentary by infectious disease specialist Paul E. Sax, M.D. about the use of remdesivir in COVID.
In a well written editorial, infectious disease specialist Paul Sax, M.D. notes that the data on remdesivir is inconsistent and that we don’t yet have an answer. It is worthwhile following the link and seeing what he has to say. The full article can be found here.
Cats, but not dogs, shed SARS-CoV-2 after infection. This is a study of seven cats and three dogs purposely exposed to SARS-CoV-2 via the transnasal route. All of the animals developed antibodies and none of the animals developed clinical symptoms. Only cats shed virus for up to five days post-infection and cats have been reported to infect other felines.
This is reassuring to COVID-19 patients who have dogs or cats at home. While we may infect these pets, there does not seem to be any significant consequence to the pets. To date, there are no cases of feline transmission to humans. The full article can be found here.
- Bosco-Lauth AM et al. Experimental infection of domestic dogs and cats with SARS-CoV-2: Pathogenesis, transmission, and response to reexposure in cats. Proceedings of the National Academy of Sciences Sep 2020, 202013102; DOI: 10.1073/pnas.2013102117
The CDC released updated guidelines (19 October 2020) for mask use on public transport. Among the recommendations are (directly quoted):
“[The] CDC strongly recommends appropriate (should you explain what appropriate means or link to the mask-specific information from below, here?) masks be worn by all passengers and by all personnel operating the conveyance while on public conveyances (e.g., airplanes, ships, ferries, trains, subways, buses, taxis, ride-shares) and within locations where people board such conveyances (e.g. airports, bus or ferry terminals, train stations, seaports).
- People should wear masks that cover both the mouth and nose when waiting or, traveling on, or departing from public People should also wear masks at an airport, bus or ferry terminal, train or subway station, seaport, or similar area that provides transportation.
- People should wear masks when traveling into, within, or out of the United States on conveyances.
- Conveyance operators transporting people should refuse boarding to anyone not wearing a mask and require all people onboard, whether passengers or employees, to wear masks for the duration of travel except in the following circumstances:
- for brief periods while eating, drinking, or taking medication
- if unconscious, incapacitated, unable to be awakened, or otherwise unable to remove the mask without assistance
- When necessary to temporarily remove the mask to verify one’s identity such as during Transportation Security Administration (TSA) screening, or when asked to do so by the ticket or gate agent, or any law enforcement official.”
The mask-specific information can be found here: https://www.cdc.gov/quarantine/masks/mask-travel-guidance.html
Week of October 7th through October 13th
Welcome to the COVID-19 Channel. This week we have updated guidelines for management of COVID-19 from the NIH, information about cytokine levels in COVID-19 compared to levels in other critically ill patients, and the peer reviewed results of the RECOVERY trial of hydroxychloroquine and the “Remdesivir for the Treatment of COVID-19” trial, both of which were released previously before peer-review.
The NIH has released updated management guidelines for COVID-19. Some of the highlights:
- There are specific recommendations for the use of of dexamethasone and remdesivir.
- There is insufficient data regarding are the use of convalescent serum or monoclonal antibodies.
- A recommendation against mesenchymal stem cells.
- Neither hydroxychloroquine nor azithromycin are recommended.
- HIV: Continue ART and prophylaxis for opportunistic infections in those with HIV.
- Shock: “The Panel recommends norepinephrine as the first-choice vasopressor (AII).”
- Shock: “For adults with COVID-19 and refractory septic shock who are not receiving corticosteroids to treat their COVID-19, the Panel recommends using low-dose corticosteroid therapy (“shock-reversal”) over no corticosteroid therapy (BII).”
- Prone Positioning: “For patients with persistent hypoxemia despite increasing supplemental oxygen requirements in whom endotracheal intubation is not otherwise indicated, the Panel recommends considering a trial of awake prone positioning to improve oxygenation (CIII).”
- Prone Positioning: “The Panel recommends against using awake prone positioning as a rescue therapy for refractory hypoxemia to avoid intubation in patients who otherwise require intubation and mechanical ventilation (AIII).”
- There are also specific recommendations about the use of prophylactic anticoagulation, other immune therapies, etc.
Anyone caring for patients with COVID-19 should review these guidelines. They cannot be easily summarized. The complete document can be found here.
Cytokine levels are higher in critical patients with sepsis and ARDS than they are in critical patients with COVID-19 and ARDS. This calls into question the relevance of “cytokine storm” in the pathophysiology of critical COVID-19. This is a study of 46 patients with COVID-19 related ARDS. They measured tumor necrosis factor (TNF), IL-6 and IL-8 levels and compared these to levels in historical patients who were critically ill with septic shock plus ARDS (51 patients), septic shock and no ARDS (15 patients), 62 multi-trauma patients and 30 patients who had out of hospital cardiac arrest. The data was collected between 2010 and 2020.
Patients with septic shock, with or without ARDS, had statistically significantly higher levels of TNF, IL-6 and IL-8 when compared to the patients with COVID-19 with ARDS.
The results of the other comparisons were variable, but levels of the three markers in trauma and cardiac arrest were either higher or the same as in COVID-19.
This suggests that “cytokine storm” may not be unduly responsible for the clinical condition of patients with COVID-19. The study is limited by the different assays that may have been used over the 10-year period. As with most things COVID-19, additional data would be welcome. The full study can be found here.
- Kox M, Waalders NJB, Kooistra EJ, Gerretsen J, Pickkers P. Cytokine Levels in Critically Ill Patients With COVID-19 and Other Conditions. Published online September 03, 2020. doi:10.1001/jama.2020.17052
Hydroxychloroquine did not help critically ill patients with COVID-19. And, in those not getting mechanical ventilation at baseline, was associated with a higher risk of the combined endpoint of intubation and death. This is the peer-reviewed publication of the RECOVERY trial hydroxychloroquine arm. 1,561 patients were randomized to hydroxychloroquine and 3,155 to usual care. There was no difference in death rates at 28-days in those intubated at baseline versus placebo (27% vs 25%). Of those not being ventilated at baseline, the hydroxychloroquine group had a higher risk of intubation or death (30.7% vs. 26.9%; risk ratio, 1.14; 95% CI, 1.03 to 1.27).
As reflected in the mortality rates, these were sick patients. This study tells us that hydroxychloroquine does not work in those who are critically ill with COVID-19. The full study can be found here.
- The RECOVERY Collaborative Group. Effect of Hydroxychloroquine in Hospitalized Patients with COVID-19. NEJM 8 October 2020 DOI: 10.1056/NEJMoa2022926
Remdesivir shortened the time to recovery in patients hospitalized with COVID-19 who had lower respiratory symptoms. There was no mortality benefit in any group. This is the peer-reviewed publication of the "Remdesivir for the Treatment of COVID-19" trial. This is a double-blind randomized placebo-controlled trial of remdesivir in 541 patients getting active drug and 521 getting placebo. All patients had lower respiratory symptoms and were rated between 4 and 7 in disease severity on a 7-point scale. The recovery time averaged 10 days (CI 95% 9 to 11 days) in those getting remdesivir and 15 days (CI 95% 13-18 days) in those getting placebo. There was no mortality benefit in any group.
The full study can be found here.
- Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the Treatment of COVID-19-final report. NEJM 8 October 2020 DOI: 10.1056/NEJMoa2007764
Week of September 30th through October 6th
This week we have an update on airborne COVID-19 transmission, more information on hydroxychloroquine as prevention, data on mask use and gas exchange in those with COPD, report of an MIS-C like illness in adults with COVID-19, and the incidence of nosocomial spread in one hospital in Boston.
The CDC confirms that COVID-19 is spread by airborne particles more than 6 feet away from the source, especially in enclosed spaces with poor ventilation.The CDC points out that activities such as exercise and singing are especially problematic. This suggests that masks should be worn when indoors even if one is more than six feet away from another person. The full statement from October 5th can be found here.
Gas exchange is not impaired in those with COPD who wear a surgical mask. This is a study of 15 healthy controls without COPD and 15 patients with COPD. Patients had to have an FEV1<50% and an FEV1/FVC<0.7. All patients had a standard 6-minute walk test. At rest, (5 and 30 minutes) there was no difference in any parameter in either gr6up while wearing the mask. Two patients with severe COPD had an expected reduction in oxygen saturation consistent with walking (a saturation decrease of only 0.35%). There was no difference in CO2 retention indicating adequate ventilation. None of the controls had any change in oxygenation. The researchers note that other studies have shown that N-95 masks may cause a clinically meaningless increase in CO2 in healthy patients.
This study supports the use of surgical masks even in those with severe COPD. However, the study is too small to be definitive. Recommendations need to be individualized but it does argue that those with mild asthma, etc. should not be exempt from mask use. The full text can be found here.
- Samannan R, Holt G. et al. Effect of Face Masks on Gas Exchange in Healthy Persons and Patients with COPD (in Press Annals of the American Thoracic Society). October 02, 2020 as 1513/AnnalsATS.202007-812RL
More data suggests prophylaxis with hydroxychloroquine does not prevent infection among health care works. This is a double blind, placebo controlled randomized study of prophylactic hydroxychloroquine in hospital health care workers. One-hundred and twenty-three of a planned 200 participants were enrolled before the study was stopped for futility. There was no difference in infection rates between those getting hydroxychloroquine and placebo (6.3% versus 6.6%).
Like most things COVD-19, we still need more data and larger trials are in the works. The full study can be found here.
- Abella BS, Jolkovsky EL, Biney BT, et al. Efficacy and Safety of Hydroxychloroquine vs Placebo for Pre-exposure SARS-CoV-2 Prophylaxis Among Health Care Workers: A Randomized Clinical Trial. JAMA Intern Med. Published online September 30, 2020. doi:10.1001/jamainternmed.2020.6319
Multisystem inflammatory syndrome in children (MIS-C) is a rare but well know complication of COVID-19 in children. This report in the MMWR describes a similar syndrome, “multisystem inflammatory syndrome in adults” (MIS-A), in adults who test positive for COVID-19. The presenting symptoms were variable including fever (75%), chest pain/palpitations, elevated troponin, hypotension, ventricular dysfunction, and GI symptoms. All of the patients had some cardiac involvement as noted on EKG, by an elevated troponin or by an abnormal echo. Of note respiratory symptoms were not prominent despite a ground-glass appearance on CT scan or pleural effusions. All patients had elevated inflammatory markers including CRP, ferritin and d-dimer. All of the patients in the US belonged to a minority group, predominantly Black and Hispanic.
The take home message here is that the manifestation of COVID-19 are protean and it is worthwhile testing critically ill patients for COVID-19 even in the absence of a fever or respiratory symptoms. The full report can be found here.
- Morris SB, Schwartz NG, Patel P, et al. Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection — United Kingdom and United States, March–August 2020. MMWR Morb Mortal Wkly Rep. ePub: 2 October 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6940e1external icon.
Finally, nosocomial spread of SARS-CoV-2 seems to be rare when appropriate precautions are taken. This is a study of all 7394 patients admitted to a single institution between March 7th and May 30th who had COVID-19 testing done. Of these, 697 were positive and 1.7% of these met criteria for possible nosocomial infection (>3 days after admission or <14 days after discharge.). Of 8370 patients who were negative for COVID-19 while hospitalized, 0.1% were diagnosed with COVID-19 within 14 days of discharge. Of all of the cases (inpatient and outpatient), only two were deemed to represent nosocomial infections.
This hospital implemented all of the CDC guidelines to prevent infection including “personal protective equipment donning and doffing monitors, universal masking, restriction of visitors, airborne precaution isolation rooms, and liberal RT-PCR testing of symptomatic and asymptomatic patients.” We can’t be sure that their determinations were accurate; the reviewers would likely have some bias towards calling cases not nosocomial. Even so, when all of these preventive measures are taken, hospitalization does not seem to be a major risk factor for acquiring COVID-19. Note that the intervention included PPE donning and duffing monitors. The full study can be found here.
- Rhee D, Baker M. et al. Incidence of Nosocomial COVID-19 in Patients Hospitalized at a Large US Academic Medical Center JAMA Netw Open. 2020;3(9):e2020498. doi:10.1001/jamanetworkopen.2020.20498
Week of September 24th through September 30th
This week we have information on Vitamin D deficiency and COVID-19, outcomes after cardiac arrest secondary to COVID-19 (dismal), CDC guidelines for Halloween activities and problems with the inclusion criteria for vaccine testing.
Low Vitamin D is associated with worse outcomes in COVID-19. This is a small, retrospective study of 235 patients hospitalized with COVID-19 who had a vitamin D level drawn at admission. The diagnosis of COVID-19 was made using RT-PCR, supportive CT scan and clinical criteria; only 31% had a RT-PCR. Thirty nanograms/ml was used as the cutoff for vitamin D deficiency. Thirty-seven percent of the patients were over age 65. Sixty-seven percent of the 235 had low vitamin D levels. Hypoxia and loss-of-consciousness were more common in the vitamin D deficient patients, but rates of intubation were the same. CRP levels were lower in those with adequate levels of vitamin D. In a subgroup analysis, those over the age of 40 who were deficient had a mortality of 20% compared to 10% in those who had adequate levels.
This study cannot prove causation; maybe those with adequate levels of vitamin D at baseline were healthier and spent more time outside. It is also such a small study that we can’t really draw firm conclusions. However, with winter coming in the Northern Hemisphere, a vitamin D supplement is relatively inexpensive, safe, and not unreasonable. The full study can be found here.
- Maghbooli Z, Sahraian MA, Ebrahimi M, Pazoki M, Kafan S, Tabriz HM, et al. (2020) Vitamin D sufficiency, a serum 25-hydroxyvitamin D at least 30 ng/mL reduced risk for adverse clinical outcomes in patients with COVID-19 infection. PLoS ONE 15(9): e0239799. https://doi.org/10.1371/journal.pone.0239799
The outcome of in-hospital cardiac arrest in COVID-19 patients is dismal. This is a study of 60 patients with COVID-19 who had an in-hospital cardiac arrest (4.6% of the total admitted population of 1309 patients). Only 3.7% had a shockable rhythm. Return of spontaneous circulation was achieved in 53% of the patients. However, none of the patients survived to discharged.
This reminds us that COVID-19 is a multisystem disease and saving the heart won’t save the patient. It should also prompt us to have end-of-life discussions with patients and family before there is a crisis. The full study can be found here.
- Thapa SB, Kakar TS, Mayer C, Khanal D. Clinical Outcomes of In-Hospital Cardiac Arrest in COVID-19. JAMA Intern Med. Published online September 28, 2020. doi:10.1001/jamainternmed.2020.4796
Older patients are being excluded from COVID-19 vaccine and treatment trials. This is a review of the all of the clinical trials of COVID-19 treatments and prevention found on the site www.clinicaltrials.gov. At least one trained research assistant reviewed the eligibility requirements of the trials. Eight-hundred and forty-seven trials were found. Of these, 23% had an age limit. For phase 3 trials, 16% had an age exclusion and 33% had exclusions “preferentially affecting older adults” (e.g. community dwelling). Sixty-one percent of vaccine trials included an age cutoff.
Patients age 65 and older make up the largest cohort of COVID-19 age related deaths (80%). This study suggests a need to broaden the age range in studies. This is especially true in vaccine trials since we know that other vaccines (e.g. influenza) are less effective in the older population. The full text can be found here.
- Helfand BKI, Webb M, Gartaganis SL, Fuller L, Kwon C, Inouye SK. The Exclusion of Older Persons From Vaccine and Treatment Trials for Coronavirus Disease 2019—Missing the Target. JAMA Intern Med. Published online September 28, 2020. doi:10.1001/jamainternmed.2020.5084
Finally, the CDC has issued suggestions about fall holiday gatherings including Halloween and Día de los Muertos. For Halloween some of the suggested low risk activities include:
- Carving or decorating pumpkins with members of your household and displaying them
- Carving or decorating pumpkins outside, at a safe distance, with neighbors or friends
- Decorating your house, apartment, or living space
- Doing a Halloween scavenger hunt where children are given lists of Halloween-themed things to look for while they walk outdoors from house to house admiring Halloween decorations at a distance
- Having a virtual Halloween costume contest
- Having a Halloween movie night with people you live with
- Having a scavenger hunt-style trick-or-treat search with your household members in or around your home rather than going house to house.
The recommendations also include information on moderate and high-risk activities and recommendations about celebrating Thanksgiving and Día de los Muertos.
Week of September 16th through September 23rd
This week we have a revision of the CDC guidance on who needs COVID-19 testing, return to sports recommendations from the American Academy of Pediatrics (AAP), information on mortality in those <21 years of age, a study that re-enforces the psychiatric toll of COVID-19 during the pandemic and a general guideline from the AAP on caring for those with special needs.
The CDC has revised their testing guidelines to include the testing of those who are asymptomatic and have been exposed to known COVID-19. They are now in line with the recommendations of the AMA. As a general note, the CDC does not recommend antibody testing but either PCR or antigen testing are appropriate. See “Weekly Update” for August 26th – September 1st for details of the AMA guidelines. The revised CDC guidelines can be found here.
- https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-overview.htmlFor patients:
The American Academy of Pediatrics (AAP) has released guidelines for returning to sports after COVID-19. These include:
- Preparticipation testing is not recommended unless there has been an exposure.
- Because of the risk of myocarditis, those with severe presentations (renal disease, hypotension, needing intubation, multisystem inflammatory syndrome, etc.) should be held out of sports for 3-6 months and must be cleared by their primary care physician and, preferably, by a pediatric cardiologist before returning to play. Testing may include an echocardiogram, a cardiac MRI or other cardiac testing (EKG, Holter monitor, exercise stress test).
- Those with “moderate” symptoms should be asymptomatic for at least 14 days and have an EKG before returning to sports. If the individual had “a prolonged fever” or any cardiac symptoms (e.g. dyspnea, chest discomfort, undo fatigue) they should be referred to a pediatric cardiologist.
- Any child exposed to COVID-19 should be held out of sports for a minimum of 14 days and, if symptomatic (e.g. infected), should be asymptomatic for at least 14 days before returning to sports.
- Return to activity should be graded and children monitored for cardiac symptoms such as dyspnea, chest pain, etc.
- Maintain physical distancing during sports activity and wear a mask except when directly in competition (e.g. wear a mast on the sidelines, during arrival and departure, etc.)
- Families should weigh the risk versus the benefit of sports including the possibility of infecting vulnerable individuals in the home.
- Covid-19 Interim Guidance: Return to Sports. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/
One-hundred and twenty-one COVID-19 related deaths have been reported in those younger than age 21. Despite the widespread nature of the COVID-19 pandemic, few deaths (121) have been reported in those less than 21 years of age. Of these deaths, 10% were younger than one year of age, 45% were Hispanic and 29% were Black. Seventy-five percent of those who died had an underlying illness including obesity, asthma/chronic lung disease, cardiovascular conditions and neurologic/developmental conditions. Of note, 38% of these children died outside of a hospital or in the ED, perhaps reflecting lack of access to care for whatever reason
The overall mortality rate in those <21 years of age is low but still something to be aware of. As in other age groups, persons of color are over-represented. The full report can be found here.
- Bixler D, Miller AD, Mattison CP, et al. SARS-CoV-2–Associated Deaths Among Persons Aged <21 Years — United States, February 12–July 31, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1324–1329. DOI: http://dx.doi.org/10.15585/mmwr.mm6937e4
Previous studies have shown an increase in depression and suicidality during the COVID-19 pandemic. This study adds to the literature. This is a study of a representative group of 1470 adults in the US who speak English looking at depressive symptoms using the PHQ-9 during the pandemic.. There were 5065 historical controls. Participants were contacted between March 31st and April 13th 2020. There was a 64% completion rate (e.g. 36% dropout). They found that during the control period 8% of respondents had depressive symptoms compared to 28% during the pandemic. While there were higher rates of depression seen in all groups, individuals with fewer resources (low wage job, savings of <$5000.00, single or divorced) were more likely to be depressed.
This reminds us again that we should be aware of the psychological toll this pandemic is having on our patients (and ourselves). It is limited by the exclusion of non-English speakers although the authors claim to have a sample representative of 97% of the population. Additionally, there was a high dropout rate. The full study can be found here.
- Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galea S. Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic. JAMA Netw Open. 2020;3(9):e2019686. doi:10.1001/jamanetworkopen.2020.19686
The American Academy of Pediatrics has released guidelines for the care of children and youth with special needs during the pandemic. This is an extensive guide covering:
- Mask use
- Multilayer risk reduction
- Specific steps to take to assure flexible and responsive accommodations
- Mental health needs
- Long term care considerations
- Financial and telemedicine implications and more.
These recommendations are specific to each individual and a quick summary does not do them justice. We would urge anyone taking care of those with special needs to see the complete document here.
Week of September 9th through September 15th
Welcome. This week we have a preliminary report on the use of granulocyte colony stimulating hormone on COVID-19 outcomes, results of a study on outcomes among those 18-34 who are hospitalized for COVID-19, new information about cardiac MRI in college athletes infected with SARS-CoV-2, and a cautionary tale about reopening restaurants and bars.
Human Granulocyte Colony-Stimulating factor (rhG-CSF) did not result in faster improvement in COVID-19 but more study is needed. 200 adult patients over age 18 were randomized to rhG-CSF plus usual care or usual care alone (100 in each group, open label, median age 45). All patients had lymphopenia at baseline and no comorbidities. Outcome was time to clinical improvement. There was no difference in time to improvement between the groups. However, fewer treated patients went on to develop critical disease (2 vs. 15) and fewer in the treatment group died (2 vs. 10). The authors conclude that “larger studies that include a broader range of patients with COVID-19 should be conducted.”
Another study of a promising treatment with relatively small numbers and in a limited population (no comorbidities…of 329 screened only 200 met criteria). As per the authors, we need more data. The full article can be found here.
- Cheng L, Guan W, Duan C, et al. Effect of Recombinant Human Granulocyte Colony–Stimulating Factor for Patients With Coronavirus Disease 2019 (COVID-19) and Lymphopenia: A Randomized Clinical Trial. JAMA Intern Med. Published online September 10, 2020. doi:10.1001/jamainternmed.2020.5503
A study that confirms what we know about MRI findings of myocarditis in COVID-19, now in patients with mild COVID-19 disease. This is study of cardiac MRI findings in 26 college athletes with a positive COVID-19 test. Importantly, none of these patients required admission or were treated with “COVID-19 specific antiviral therapy.” 12 of the 26 had mild COVID-19 symptoms and the other 14 were asymptomatic. All had normal EKGs and none had an elevated troponin. 12 of the 26 had some cardiac finding on MRI. Myocarditis was found in four, two of whom were asymptomatic with the other two having mild symptoms. Findings of prior myocardial injury was found in the other eight.
Myocarditis is a risk for sudden death due to arrhythmia. This is a cautionary tale about the effects of COVID-19 even on those with mild or no symptoms. Whether we should exclude these athletes from competition is unknown. The full article can be found here.
- Rajpal S, Tong MS, Borchers J, et al. Cardiovascular Magnetic Resonance Findings in Competitive Athletes Recovering From COVID-19 Infection. JAMA Cardiol. Published online September 11, 2020. doi:10.1001/jamacardio.2020.4916
Of young adults (age 18-34 years) requiring hospitalization for COVID-19 2.7% died, 10% required intubation and 21% require ICU care. Cases of COVID-19 are increasing in young adults, including those returning to college. This is a study of 3222 individuals age 18-34 years admitted for COVID-19 to 419 hospitals. Patients admitted for pregnancy were excluded. Fifty-seven percent were Black or Hispanic.
Twenty-one percent required ICU care, 10% required intubation, and 2.7% died. As in other studies, morbid obesity and hypertension were associated with worse outcomes.
While younger individuals are less likely to become seriously ill with COVID-19, youth does not confer immortality. We need to stress social distancing and mask wearing for all populations, not only those who are older. This also re-enforces the excess burden of this disease in Blacks and Hispanics. The full text can be found here.
- Cunningham JW, et al. Clinical Outcomes in Young US Adults Hospitalized with COVID-19. JAMA Intern Med. Published online September 9, 2020. doi:10.1001/jamainternmed.2020.5313
Restaurants, bars and coffee shops are high risk areas for COV ID-19 transmission. This is a case-controlled study of adults from 11 health care institutions looking at exposures in various settings and the frequency of diagnosed COVID-19. They administered a structured interview to 154 symptomatic COVID-19 positive patients and 160 controls out of 802 contacted (and a pool of 615 potential cases and 1,012 controls).
The participants were asked about exposures to the following locations: Shopping, home of < 10 individuals, restaurants, office settings, salons, home of > 10 individuals, gyms, public transportation bars/coffee shops and religious gatherings.
After adjusting for known exposure to COVID-19, bars, coffee shops and restaurants fell out as significant sources of exposure.
Of note, church/religious gatherings and gyms also strongly trended as sources of exposure and likely would be significant in a larger study. For example only 20 of the participants, 12 COVID-19 positive and 8 COVID-19 negative, attended church. And, we know from empirical data that religious gatherings can be a source of transmission.
This study suffers from a relatively small sample. They did not do a power analysis, so we don’t know if this study is large enough to rule out differences that are there (type II error). Studies based on participant recall are also subject to “recall bias”, that is people may or may not remember their exposures correctly. Finally, a significant number invited to do so declined to participate. The full study can be found here.
- Fisher KA, Tenforde MW, Feldstein LR, et al. Community and Close Contact Exposures Associated with COVID-19 Among Symptomatic Adults ≥18 Years in 11 Outpatient Health Care Facilities — United States, July 2020. MMWR Morb Mortal Wkly Rep 2020;69:1258–1264. DOI: http://dx.doi.org/10.15585/mmwr.mm6936a5external icon.
- James A, Eagle L, Phillips C, et al. High COVID-19 Attack Rate Among Attendees at Events at a Church — Arkansas, March 2020. MMWR Morb Mortal Wkly Rep 2020;69:632–635. DOI: http://dx.doi.org/10.15585/mmwr.mm6920e2external icon.
Week of September 2nd through September 8th
This week we have new information on the use of steroids in COVID-19, guidance from the NIH on the use of convalescent serum (which is contrary to the FDA recommendation) and new information on the impact of COVID-19 on community health center visits and on immunizations.
The NIH suggests that convalescent plasma is not standard of care and needs more study. This is despite the endorsement by the FDA. What we know so far: The studies that have looked at convalescent plasma show that it is relatively safe. However, the randomized trials have all been stopped early and have not reached statistical significance (though there is a hint of a benefit). Open label studies have been equivocal with some being positive and others negative. What is new: The NIH suggests that the data is inconclusive, and that convalescent plasma should not be considered the standard of care. The main points are:
“Based on the available evidence, the Panel has determined the following:
- There is insufficient data to recommend either for or against the use of convalescent plasma for the treatment of COVID-19.
- Available data suggest that serious adverse reactions following the administration of COVID-19 convalescent plasma are infrequent and consistent with the risks associated with plasma infusions for other indications.
- The long-term risks of treatment with COVID-19 convalescent plasma [are unknown]. [It is also not clear] whether its use attenuates the immune response to SARS-CoV-2, making patients more susceptible to reinfection.
- Convalescent plasma should not be considered standard of care for the treatment of patients with COVID-19.
- Prospective, well-controlled, adequately powered randomized trials are needed to determine whether convalescent plasma is effective and safe for the treatment of COVID-19. Members of the public and health care providers are encouraged to participate in these prospective clinical trials.” The full statement can be found here.
Other problems include the lack of a standardized dose, how to appropriately determine the antibody levels in convalescent plasma, etc. While more conservative, the NIH statement better reflects the state of the art concerning convalescent plasma in COVID-19.
- The COVID-19 Treatment Guidelines Panel’s Statement on the Emergency Use Authorization of Convalescent Plasma for the Treatment of COVID-19
- FDA Clinical Memorandum, Emergency Use Authorization for COVID-19 convalescent plasma 23 August 2020.
- Ling L. et al. Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19 A Randomized Clinical Trial JAMA. 2020;324(5):460-470. doi:10.1001/jama.2020.10044 (initially published in June, now updated with corrections).
A meta-analysis confirms the value of steroids in critically ill patients with COVID-19. This is a meta-analysis of 7 randomized trials of 1700 patients of whom 37% died. Six of the 7 trials were deemed to have a low risk of bias. Criteria for patient enrollment differed between the trials from 6L/min of oxygen to intubation. Treatments included high or low dose steroids. Outcomes were mortality 28 days after randomization (two studies only reported on 21-day mortality). The absolute risk of mortality in ventilated patients was 30% with steroids vs. 38% with placebo (NNT=8). For those not ventilated the absolute risk of mortality was 23% for corticosteroids vs 42% for usual care or placebo (NNT=5). The full study can be found here.
This study confirms the benefit of corticosteroids in critically ill patients with COVID-19. Based on this meta-analysis, the World Health Organization (WHO) recommends 6 mg of dexamethasone orally or intravenously daily or 50 mg of hydrocortisone intravenously every 8 hours for 7 to 10 days in seriously ill patients.
This does not mean that every patient with COVID-19 should get steroids. But it seems to be helpful in those with “severe” disease.
- The WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group. Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19: A Meta-analysis. Published online September 02, 2020. doi:10.1001/jama.2020.17023
Community health centers (CHCs) are a significant locus of COVID-19 testing. Additionally, preventive service visits dropped dramatically from 1/1/20-5/1/20 compared to historical controls. This is a study of CHCs from 21 states comprising 431 unique CHCs that use the same electronic medical record. In that period, 33,226 patients (1.7% of the total seen) were tested for COVID-19. Of these, 28% were positive. Importantly, the number of face-to-face visits as did well child visits, Pap tests, mammograms and hemoglobin A1c testing. The full study is available here. Other studies have documented a steep decline in routine immunizations despite an infrastructure that is adequate to administer said vaccines.
These studies remind us that routine health care may be suffering as a result of COVID-19. We need to redouble our effort to reassure our patients that, properly done, routine visits are safe.
- Heintzman J, O’Malley J, Marino M, et al. SARS-CoV-2 Testing and Changes in Primary Care Services in a Multistate Network of Community Health Centers During the COVID-19 Pandemic. Published online August 31, 2020. doi:10.1001/jama.2020.15891
- Vogt TM, Zhang F, Banks M, et al. Provision of Pediatric Immunization Services During the COVID-19 Pandemic: an Assessment of Capacity Among Pediatric Immunization Providers Participating in the Vaccines for Children Program — United States, May 2020. MMWR Morb Mortal Wkly Rep 2020;69:859–863. DOI: http://dx.doi.org/10.15585/mmwr.mm6927a2external icon.
- Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration — United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:591–593. DOI: http://dx.doi.org/10.15585/mmwr.mm6919e2
Week of August 26th through September 1st
This week we have more information about anticoagulation in patients with COVID-19, a controversy about who to test after an exposure to COVID-19, information on the expanded use of remdesivir, and the ocular manifestations of COVID-19 in children.
Routine prophylactic anticoagulation seems to be of benefit in those hospitalized with COVID-19. This is a retrospective study of either prophylactic, full dose or no anticoagulation in 4389 patients >18 years of age admitted for COVID-19 at 5 hospitals in New York. Exclusion criteria included discharge within 48 hours of admission, being treated with both full dose and prophylactic dose anticoagulation during the hospitalizations, or <48 hours of anticoagulation.
The outcome was in hospital mortality with a secondary endpoint of intubation. They tried to adjust for other variables including history of hypertension, BMI, chronic kidney disease, etc.
The risk of death or intubation was lower in those on either full dose or prophylactic dose anticoagulation (HR 0.53 (95%CI 0.45-0.64 and HR=0.50 95% CI 0.45-0.57 respectively). Bleeding was 3.0% with full anticoagulation and was about half this in the no anticoagulation and prophylactic anticoagulation groups. In a subgroup analysis, there was no difference between the full dose and prophylactic dose heparin, if started within 48 hours of admission.
This was a retrospective study, but suggests that early prophylactic therapy with heparin reduces mortality and that low dose is equivalent to full dose anticoagulation. The bleeding risk seems acceptable. More information on full dose anticoagulation, when it arrives will be welcome. As is the case with many of these trials, it isn’t randomized so cannot give us a definitive answer; one cannot control for every variable. It does, however, suggest that prophylactic dose anticoagulation is helpful.
Nadkarni, GN et al. Mortality, Bleeding and Pathology Among Patients Hospitalized with COVID-19: A Single Health System Study J Am Coll Cardiol. 2020 Aug 26. Epublished DOI:10.1016/j.jacc.2020.08.041
The FDA has authorized remdesivir for patients with all severities of COVID-19 disease. The emergency authorization document can be found here. This is based on the study that we covered last week, the discussion which can be found here. In that study the authors concluded that “Patients randomized to a 5-day course of remdesivir had a statistically significant difference in clinical status compared with standard care, but the difference was of uncertain clinical importance.” The salient points are:
- The FDA finds “it is reasonable to believe that remdesivir (Veklury) may be effective”.
- The FDA is “no longer limiting its (remdesivir) use to the treatment of patients with severe disease.”
We really don’t know if this will help the clinical (not statistical) situation of patients. As with most things COVID-19, we are waiting for more data.
FDA Authorization Document: https://www.fda.gov/media/137564/download
Spinner, CD et al. Effect of Remdesivir vs Standard Care on Clinical Status at 11 Days in Patients with Moderate COVID-19A Randomized Clinical Trial JAMA. Published online August 21, 2020. doi:10.1001/jama.2020.16349
Saliva based PCR performs as well or better than nasopharyngeal (NP) swab- based PCR. This is as study in two parts. In the first phase, 70 inpatients with known COVID-19 by NP swab were tested using a saliva sample. The testing showed “more” copies of SARS-CoV-2 RNA in saliva when compared to the NP specimens (the confidence intervals overlap, however). Ten days post infection “more” of the saliva tests were positive (81% vs. 71%, but again the confidence intervals overlap).
In the second part of the study, they screened 495 asymptomatic health care workers using both saliva and an NP swab. They found 13 individuals without symptoms who tested positive, confirmed by a second test. The NP swab was negative in 7 of them.
This is not the “rapid” antigen saliva test that has been in the news recently. All of these were done by PCR. However, a saliva-based test may be more acceptable to patients and may yield more uniformity in specimen collection (you don’t have to have an uncomfortable NP swab specimen that may or may not be adequate). This study suggests that the saliva test is at least as good as using an NP swab.
Wyllie AL et al. Saliva or Nasopharyngeal Swab Specimens for Detection of SARS-CoV-2 NEJM August 28, 2020 DOI: 10.1056/NEJMc2016359
Confusion about who to test. This week the CDC suggested that asymptomatic individuals with COVID-19 exposure need not be tested. This was subsequently dialed back but this clarification has not been changed on the CDC website. We are reposting the summary of the AMA guidelines for testing and a link to the AMA’s recommendations.
The American Medical Association (AMA) has released testing recommendations since testing is likely going to be limited, at least through the remainder of 2020. They point out that the supply of swabs is finally adequate but that reagents, viral transport media, pipette tips and other testing paraphernalia are still in short supply.
They recommend prioritizing testing for high risk individuals:
- Patients exhibiting signs/symptoms of COVID-19
- Those with a known exposure to COVID-19 (e.g. as in contact tracing).
- Those required to have a negative COVID-19 test in order to get needed medical care such as elective surgery, chemotherapy, etc.
- Health care workers
A second tier would be those not at immediate risk of infection, including:
- Those wishing to travel
- Those wishing to attend social engagements
Those returning to work or school.
They emphasize counseling those being tested to stay quarantined until the results are reported, and a negative test is confirmed. The full statement can be found here.
AMA Public Health, Considerations for physicians ordering SARS-CoV-2 PCR diagnostic testing. https://www.ama-assn.org/delivering-care/public-health/considerations-physicians-ordering-sars-cov-2-pcr-diagnostic-testing
Finally, and briefly, ocular symptoms may occur in youngsters with COVID-19 who are otherwise asymptomatic. This is a limited series but worth raising awareness. In this series, 22% of children with COVID-19 had some ocular finding (eye rubbing, discharge, redness, etc.). More importantly, 4% of children had ocular symptoms as their initial presentation.
This does not mean we should test all children with eye symptoms for COVID-19, but we should at least ask a question about exposure.
Ma, N et al. Ocular Manifestations and Clinical Characteristics of Children With Laboratory-Confirmed COVID-19 in Wuhan, China JAMA Ophthalmol. Published online August
Week of August 18th through August 25th
This week we have new information on remdesivir, information on the use of shields as an adjunct to masks, an FDA statement on convalescent serum, and an AMA suggestion on how to apportion testing since demand is expected to out strip resources for the remainder of 2020.
Remdesivir yields statistically, but perhaps not clinically, significant benefit to those with moderate COVID-19
596 patients were randomized to remdesivir 200mg IV on day 1 and then 100mg IV per day for a total of 5 or 10 days. Patients were included if they had a positive PCR within 4 days of randomization and had infiltrates but with an oxygen saturation of >94% on room air. Patients also had to have transaminases of <5X upper limit of normal and a creatinine clearance of >50ml/min. Outcomes included the number of patients discharged by day 14 (original outcome); clinical assessment on a 7 point scale by day 11 was added as the primary outcome during the trial.
The 10-day course did not seem to yield any improvement in clinical status (p=0.18) whereas the 5-day course did (p=0.02). The difference was an odds ratio of 1.65 (CI 95% 1.09-2.48) for improvement.
The authors conclude that “Patients randomized to a 5-day course of remdesivir had a statistically significant difference in clinical status compared with standard care, but the difference was of uncertain clinical importance.” The full text can be found here.
A couple of points: 1) This doesn’t mean that remdesivir doesn’t work in more severe disease. We would expect people with more mild disease to benefit less from an intervention since they may have done well anyway. 2) As nicely pointed out by the authors, statistical significance isn’t the same as clinical significance. One can have a statistical difference between two groups that is clinically meaningless. 3) Finally, it doesn't make sense that a 10 day course would be worse than a 5 day course unless remdesivir is doing something untoward. So likely this is likely due to chance, especially since those in the 10 day group got an average of only 6 days of treatment. See the BMJ remdesivir guideline here.
Spinner, CD et al. Effect of Remdesivir vs Standard Care on Clinical Status at 11 Days in Patients with Moderate COVID-19A Randomized Clinical Trial JAMA. Published online August 21, 2020. doi:10.1001/jama.2020.16349
Shields are additive to masks when it comes to protecting healthcare workers from COVID-19. This is an Indian observational study of 62 community health workers who visited 5880 homes to explain social distancing, quarantine, etc. By report, workers wore masks and maintained social distancing. All workers were also housed in separate rooms in hostels to prevent them from getting infected by contact with the community (so theoretically they only place they would be exposed to SARS-CoV-2 was during their visits to homes). In a 10 day period 12 of these workers (19%) tested positive for SARS-CoV-2. Thereafter, the remaining 50 workers wore both face shields and masks and visited a total of 18,228 homes over a one month period. No community health workers became infected with SARS-CoV-2 during this phase of the study. The full text is available here.
This study suggests that face shields are additive to masks in preventing the spread of COVID-19.
Bhaskar E, Arun S. SARS-CoV-2 Infection Among Community Health Workers in India Before and After Use of Face Shields JAMA. Published online August 17, 2020. doi:10.1001/jama.2020.15586
The FDA has approved the emergency use of COVID-19 convalescent plasma (CCP) for treatment. The salient points are:
The two randomized, controlled studies of CCP were stopped early, therefore did not have the power to prove the effectiveness of CCP. However, both hint at benefit.
Some non-randomized, controlled trials showed benefit and some not.
Retrospective matched cohort studies have been positive but have limitations.
CCP is safe based on a study of 20,000 patients coordinated by the Mayo Clinic (<1% transfusion reaction, <1% thromboembolic events but 3% cardiac events). None of the cardiac or thromboembolic events were deemed to be caused by CCP.
CCP should be tested for SARS-CoV-2 antibodies and should meet a certain level of antibody to be deemed “high titer CCP”. Other units should be labeled as “CCP of low titer”.
The initial dose should be 200 ml but we have no firm experience and dosing should be based on “the prescribing physician’s medical judgement and the patient’s clinical response.”
The complete statement can be found here.
FDA Clinical Memorandum, Emergency Use Authorization for COVID-19 convalescent plasma 23 August 2020. https://www.fda.gov/media/141480/download
The American Medical Association (AMA) has released testing recommendations since testing is likely going to be limited at least through the end of 2020. They point out that the supply of swabs is finally adequate but that reagents, viral transport media, pipette tips and other testing paraphernalia are still in short supply.
They recommend prioritizing testing for high risk individuals:
Patients exhibiting signs/symptoms of COVID-19
Those with a known exposure to COVID-19 (e.g. as in contact tracing).
Those required to have a negative COVID-19 test in order to get needed medical care such as elective surgery, chemotherapy, etc.
Health care workers.
A second tier would be those not at immediate risk of infection including:
Those wishing to travel
Those wishing to attend social engagements
Those returning to work or school.
They emphasize counseling those being tested to stay quarantined until the results are reported, and a negative test is confirmed. The full statement can be found here.
AMA Public Health, Considerations for physicians ordering SARS-CoV-2 PCR diagnostic testing. https://www.ama-assn.org/delivering-care/public-health/considerations-physicians-ordering-sars-cov-2-pcr-diagnostic-testing
Week of August 11th through August 17th
Welcome to the weekly COVID-19 update. This week we have information on two studies about the efficacy of different types of masks in preventing aerosolization of particles, the increase of disease among children, an MMWR article about the mental health effects of COVID-19 and American Academy of Pediatrics guidelines on the reopening of schools. Finally, we are including a link to the CDC website listing the sanitizers that contain methanol and which should be avoided.
Tests of masks: Behind the ear-loop masks are not particularly useful for preventing the aerosolization of particles; data on “neck gaiters” inconsistent.
The first study looked at the effectiveness of different styles of masks at preventing the aerosolization of particles. They had an individual wearing each mask say, “Stay healthy people” and measured the particles produced. There was a control using no mask and each mask was tested 10 times. They found in order of effectiveness:
- N95 masks were the most effective followed by: Surgical masks, 3 layer polypropylene/cotton/polypropylene masks, 2 layer polypropylene/polypropylene, followed by two layer cotton masks.
- Bandanas were the least effective.
- “Neck Gaiters” didn't perform well. This data has been questioned in an unpublished small study using a different methodology.
- A full list can be found here.
A separate trial used the traditional Occupational Safety and Health Administration’s (OSHA) Quantitative Fit Testing Protocol for Filtering Facepiece Respirator to test 29 different “hospital” masks. They found that reused N95 masks treated with ethylene oxide or hydrogen peroxide maintained their effectiveness. The same held true for “expired” masks from 2009 and 2011. However, they also found that surgical masks with “behind the ear” straps were the least effective type of surgical masks (38% filtration efficacy) when compared to masks that tie or use “over-the-head” elastic. Additionally, imported, non-NIOSH approved N95 masks did not perform to the N95 standard (filtering as little as 80% of particles).
Both studies have significant limitations including small numbers. And, the first study was designed as a proof-of-concept of the procedure to measure aerosolization. The takeaway message is that tie masks/over the head masks are better than behind the ear loops; neck gaiters may be counterproductive. If our patients are wondering what masks they should buy, this will provide some guidance.
Fischer, EP et al. Low-cost measurement of facemask efficacy for filtering expelled droplets during speech Science Advances 07 Aug 2020:
eabd3083 DOI: 10.1126/sciadv.abd3083 (from AAAS)
Sickbert-Bennett EE et al. Filtration Efficiency of Hospital Face Mask Alternatives Available for Use During the COVID-19 Pandemic JAMA Intern Med. Published online August 11, 2020. doi:10.1001/jamainternmed.2020.422-1
Mental health disorders including suicidality are increasingly common during the COVID-19 pandemic. This is a study from the CDC that invited 9900 adults to complete a web-based survey of whom 5400 (55%) chose to participate. Of these, 1,729 had completed a prior survey. Forty-one percent of respondents noted some mental health issue, including 31% who reported anxiety or depression, 13% reported starting or increasing substance abuse and 11% had contemplated suicide in the last 30 days. Suicidal thoughts were most common in minority communities (Hispanic, Black) but also among unpaid caregivers and essential workers.
There are some limitations to this study, including possible selection bias: Those who had mental health issues may have felt it more important that they be heard and may have been more likely to participate. Still, it is a stark reminder of the social and mental health aspects of COVID-19 and a signal to all healthcare providers to stay attuned to the mental health needs of patients during the pandemic.
Czeisler MÉ et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–1057. DOI: http://dx.doi.org/10.15585/mmwr.mm6932a1external icon.
COVID-19 infection rates are increasing in the pediatric population. The American Academy of Pediatrics has compiled COVID-19 data from 49 states, the District of Columbia, New York City, Puerto Rico and Guam. The data is incomplete from Texas and New York. The bottom line is that 9% of COVID-19 cases in the US are in pediatric patients under age 18 with a cumulative case count of 380,174. The percent of positive tests range from 3.7%-18.6% depending on the state.
While transmission from young children 0-9 years of age seems to be less likely than in other age groups, transmission from those 10-17 seems to be higher. This has implications for schools reopening.
American Academy of Pediatrics. Children and COVID-19: State Data Report https://downloads.aap.org/AAP/PDF/AAP%20and%20CHA%20-%20Children%20and%20COVID-19%20State%20Data%20Report%208.6.20%20FINAL.pdf
Park YJ et al. Contact tracing during coronavirus disease outbreak, South Korea, 2020. Emerg Infect Dis. 2020 Oct (early release) https://doi.org/10.3201/eid2610.201315
Finally, the American Academy of Pediatrics has released a detailed set of guidelines on the safe return to classroom teaching. The key points are:
- Classroom teaching is ideal but needs to be done in a safe manner.
- Flexibility is key; if transmission rates go up there should be a rethinking of policy.
- Physical distancing measures for students should be in place including maintaining 6 feet between students; students over 2 years of age should wear masks. Three feet may be adequate if masks are worn and students are asymptomatic. There are specific mask recommendations for those hard of hearing, etc. See the link below.
- Adults should maintain a 6-foot distance between students and other school personnel.
- Physical barriers (e.g. plexiglass) should be in place where appropriate.
- Staggered drop-off and pickup times should be implemented to prevent crowding.
- Classes should not be multi-period/multi-classroom; cohorts should stay together as much as possible.
- Meals should be taken at the desk and not in a cafeteria setting.
This is a detailed guideline with suggestions based on student age, physical ability, etc. The full guideline can be found here.
American Academy of Pediatrics: COVID-19 Planning Considerations: Guidance for School Re-entry https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/
Finally, the FDA is keeping a current list of dangerous hand sanitizers that contain methanol and 1-propanol. There have been reports of systemic toxicity secondary to ingestion of these products. And, the FDA warns of the risk of toxicity if used topically. A full list of these products can be found here at the bottom of the linked page.
Week of August 4th through August 10th
This week we have a practice guideline from the United Kingdom for the use of remdesivir, a relaxing of travel restrictions issued by the State Department, a report on confusion as a presenting symptom of COVID-19, a negative study on convalescent serum for treatment and a positive study of IL-6 inhibitors, both of which have major caveats. We also have data on PPI use and COVID-19 risk.
The British Medical Journal (BMJ) has released a treatment guideline for the use of remdesivir in the United Kingdom based on randomized trials with a total 1300 patients. This guideline applies to patients with one of the following:
- A respiratory rate of >30 or
- Respiratory distress or
- An SpO2 <94% on room air or
- Who require intensive care admission.
For this population they suggest remdesivir 100mg IV QD for 5-10 days. It is a weak recommendation because of the low quality of the data.
Following this guideline will (at best) reduce mortality by 85 patients out of 1000. It has little or no effect on the duration of hospitalization but may reduce the duration of ventilation.
The recommendations are weak based on the limited number and quality of studies. However, this can help advise practice.
Remdesivir for severe COVID-19: a clinical practice guideline BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2924 (Published 30 July 2020)
The State Department has relaxed international travel rules. Individual states within the United States have strengthened theirs and the CDC has made no change. Twenty-four states now have some sort of travel restrictions for visitors with some states requiring a 14 day quarantine before engaging in any activities (a reasonably up to date list can be found here).
At the same time, the State Department has relaxed limits on international travel. The Global Level 4 Health Advisory was lifted on August 6th, 2020. However, many areas are still considered problematic. What this means is that each country needs to be assessed individually when determining the risk of travel. A list can be found here.
The CDC has not changed their recommendations which can be found here.
Note that some of the links on the CDC website pointing to their travel recommendations are broken but this direct link works.
State Department: https://travel.state.gov/content/travel/en/traveladvisories/traveladvisories.html/
Studdert,DM et al. Partitioning the Curve — Interstate Travel Restrictions During the Covid-19 Pandemic5 August 2020 DOI: 11056/NEJMp2024274
Interleukin-6 inhibitors may (or may not) be of benefit when used early, although the study methodology is not the best. This is an observational study of the use of sarilumab or tocilizumab in 255 patients with COVID-19. The drugs were initially used in critically ill patients but later on less ill patients were included. The first group included those requiring >45% FiO2 and elevated markers of inflammation. This was liberalized to an Fi02 requirement of 27%-33% or an A-A gradient of >50mmHg plus elevated inflammatory markers. 86% of patients were discharge alive.
After adjusting for age, obesity, period of care, CRP, and the need for mechanical ventilation, there was no difference in outcome for the severe group (compared to a mixed group of historical controls from a different institution). The less severe group had a mortality rate of 2.7% which was lower than historical controls.
This study suffers from the same problems found in many other COVID-19 trials: No randomization of patients to treatment or placebo. We don’t know how many in the lower risk group would have gone on to die without treatment. What can we take from this study? We need more and better trials. In fact, the authors state that “the medical community awaits more definitive results from randomized controlled trials.”
Sinha P. et al. Early administration of Interleukin-6 inhibitors for patients with severe Covid-19 disease is associated with decreased intubation, reduced mortality, and increased discharge Internantional Jornal of Infectious Disease July 25, 2020 DOI:https://doi.org/10.1016/j.ijid.2020.07.023
Convalescent plasma may not be effective in patients with severe and life threatening COVID-19. This was an open-label, placebo control study of 103 patients with severe COVID-19 defined as “severe (respiratory distress and/or hypoxemia)” or “life-threatening (shock, organ failure, or requiring mechanical ventilation).” Patients were randomized to convalescent plasma (n=52) or standard care (n=51). Outcome included time to clinical improvement, reduced severity of disease and mortality at 28 days (among others). There was no outcome difference between the two groups.
This study was planned for 200 patients and was stopped early which may have led to a type II error (not enough patients to see a difference if one is present). For example, clinical improvement was seen 52% of those getting convalescent plasma versus 43% in the control group. Likewise, mortality at 28 days was 16% versus 24%. These were not statistically different, but the study may have been underpowered. As in most COVID-19 studies, we need more and better data.
Ling L. et al. Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19 A Randomized Clinical Trial JAMA. 2020;324(5):460-470. doi:10.1001/jama.2020.10044 (initially published in June, now updated with corrections).
An online survey suggests an association between PPI use and COVID-19 infection. This is an online survey of 264,058 individuals. Of these 86,602 (22%) chose to participate of whom 61% noted a prior history of abdominal pain, heartburn or GERD. 6% of these patients were COVID-19 positive.
There was an association between PPI use and rate of COVID-19 (OR 3.8 with BID use for > 6 months). This association was not found with H-2 blockers.
This is an association and does not necessarily mean causality. There were a similar associations between PPIs and dementia, pneumonia and chronic kidney disease reported which was found to be not true in a randomized study. Additionally, there is no doubt selection bias: only 22% of individuals chose to participate.
What should we take from this? Don’t use PPIs unless they are necessary and use the lowest dose possible to achieve your goal. The same is true of all medications, of course.
Almario CV et al. Increased risk of COVID-19 among users of proton-pump inhibitors. Am J Gastroenterol 2020. Preprint at: https://journals.lww.com/ajg/Documents/AJG-20-1811_R1(PUBLISH%20AS%20WEBPART).pdf
Moayyedi P et al. Safety of proton pump inhibitors based on a large, multi-year, randomized trial of patients receiving rivaroxaban or aspirin. Gastroenterology 2019 May 29; [e-pub]. (https://doi.org/10.1053/j.gastro.2019.05.056)
Finally, isolated mental status changes can be the initial presenting symptom of COVID-19. This is a report of 4 elderly patients with dementia who presented with mental status changes before the onset of fever, cough, etc. It just reminds us to be aware of atypical presentations of COVID-19.
Ward CF et al. Altered mental status as a novel initial clinical presentation for COVID-19 infection in the elderly. Am J Geriatr Psychiatry 2020 Aug; 28:808. (https://doi.org/10.1016/j.jagp.2020.05.013)
Week of July 28th through August 3rd
This week we have more information on the intermediate sequelae of COVID-19, information on school closures and transmission, not-very-helpful information on antibody titers post-COVID-19 infection and useful information on antibody titers to confirm COVID-19 in those suspected cases where a PCR is negative.
Antibody testing at 2 weeks seems to accurately reflect a patient’s COVID-19 status. There has been quite a bit of confusion regarding diagnosing COVID-19 via antibody test and the CDC currently does not recommend antibody testing to diagnose the presence or absence of COVID-19. This study sheds some additional light on the subject.
This is a study of 115 individuals hospitalized for COVID-19, some of whom were diagnosed clinically despite the absence of a positive PCR. The control group consisted of 513 samples of patients not known to have COVID-19 (one of whom had a presumed false positive antibody test). At 14 days post symptom onset, IgG to SARS-CoV-2 spike protein was of 0.976 (95% CI, 0.928 to 0.995) sensitive and 0.988 specific (CI, 0.974 to 0.995). Several of the patients clinically classified as COVID-19 but with negative PCR proved to have COVID-19 by IgG levels. Sensitivity and specificity fell off rapidly if the test was done <14 days prior to PCR/clinical diagnosis. Alternatively, antibody levels remained positive for at least 58 days.
Current CDC criteria do not recommend antibody testing to determine the presence or absence of COVD-19. This study suggests that in patients whose condition is uncertain, antibody testing at least 14 days after the onset of symptoms might be helpful. There is at least one caveat: this was done at a single center using a single manufacturer’s test (Euroimmun Anti-SARS-CoV-2 ELISA). The results may have been different using a different test and different test operators.
- Caturegli G, Materi J, Howard BM, Caturegli P. Clinical Validity of Serum Antibodies to SARS-CoV-2: A Case-Control Study [published online ahead of print, 2020 Jul 6]. Ann Intern Med. 2020;M20-2889. doi:10.7326/M20-2889
Antibody levels do drop off over time, but the clinical significance is unknown. This is a study of serial IgG antibody levels in 34 COVID-19 patients who had at least two IgG antibody levels. They found that the half-life of antibodies to COVID-19 is 36 days (95% CI 26-60 days).
There has been much made in the news of the rapid decay in COVID-19 antibody levels. This has been raised as a reason that a vaccine may not be viable. However, we expect serum antibody levels to wane over time. This is the nature of the world. It does not mean that we won’t have an anamnestic response similar to our response to other diseases (e.g. tetanus) after immunization. We may not know this answer for a while; it is ethically suspect to expose recovered COVID-19 patients and those who participate in vaccine trials to SARS-CoV-2 to test their response. Time will provide us with an appropriate natural history experiment.
- Ibarrondo FJ et al. Rapid Decay of Anti–SARS-CoV-2 Antibodies in Persons with Mild Covid-19, NEJM July 21, 2020 DOI: 10.1056/NEJMc2025179
More data on cardiac sequelae. This is a prospective study of 100 patients with a history of COVID-19 diagnosed by PCR; the median age was 49 (45-53 range). Fifty-three percent were men. Importantly, 57% were treated as outpatients (e.g. didn’t have severe COVID-19). A cardiac MRI was done between 64-92 days after initial COVID-19 diagnosis. These patients were compared to 50 health patients and 57 risk factor matched patients. Exclusion criteria included referral for cardiac MRI (CMR) for active symptoms. Of those with a history of COVID19 tested, 78% had evidence of cardiac involvement with 60% showing current involvement. The mean left ventricular ejection (LVEF) fraction was 56% in those with a history of COVID-19 compared to 61% in risk-factor matched controls and 60% in healthy controls. Residual symptoms included atypical chest pain (17%), palpitations (20%, shortness of breath (36%) and a decrease in daily activities (25%). There were no differences in patients who were treated at home versus those needing hospitalization.
It is still not clear what to do with this data. Longer term follow-up of symptoms and LVEF would be helpful. It does remind us that not all patients are asymptomatic after discharge from hospital and that even “mild”, non-hospitalized cases can have long term consequences.
- Puntmann, VO et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19) JAMA Cardiol. Published online July 27, 2020. doi:10.1001/jamacardio.2020.3557
We now have data on school closures and the associated decrease in risk for COVID-19 infections. This can help inform return-to-school decisions. All 50 states in the U.S. closed schools in March 2020 before data on the effectiveness of this intervention was known. This study was done between March 9th and May 7th 2020 and looked at mortality and cases per 100,000 before and after school closure. Before school closures, the incidence of infection was going up by 265% per week. After school closure it dropped by 62% per week (with a lag period to allow for COVID-19 incubation). Mortality also dropped by 58% per week. The authors tried to adjust for stay-at-home/shelter-in-place orders, business closures and limits on the size of gatherings in their results.
Unfortunately, it is difficult to tease out exactly what the role of school transmission is since other control efforts (e.g. stay-at-home orders) often occurred concomitantly. It may be that parents staying at home to take care of their children was the driver of lower transmission rates; we need to remember that association doesn’t necessarily mean causation. Nevertheless, there is an association between school closure and both transmission and mortality even if this is secondary to other social distancing measures taken at the same time.
Auger KA et al. Association Between Statewide School Closure and COVID-19 Incidence and Mortality in the US JAMA. Published online July 29, 2020. doi:10.1001/jama.2020.14348
Last week we reported about intermediate term clinical sequelae of COVID-19 from a study out of Italy. This week we have similar, shorter term data, from the CDC (14-21 days after positive a PCR).
This is a phone interview of 292 randomly selected individuals done 14-21 days after having a positive test for COVID-19 who were treated as outpatients (e.g. did not have severe disease). Of these 94% reported one or more symptom at the time of testing (6% were asymptomatic). Thirty-five percent still reported one or more symptoms at follow-up (a median 16 days from the positive test) including 47% of those over age 50. Of those with cough, fatigue or dyspnea at the time of testing, 43%, 35% and 29% reported these symptoms at follow-up. There were no differences in symptom persistence based on gender, insurance status or ethnicity. However, hypertension, obesity and immunosuppression were all associate with continued symptoms.
These results aren’t surprising since the symptom documentation was within three weeks of first testing positive. But we need to view the numbers with a jaundiced eye. The researchers started with a database of 583 patients of whom only 292 were interviewed; it could be that those unable to be reached were sicker and less likely to answer the phone or perhaps even hospitalized. Nonetheless, while the data is incomplete, this study still provides a window into what symptoms remain two weeks after PCR positivity.
- Tenforde MW, Kim SS, Lindsell CJ, et al. Symptom Duration and Risk Factors for Delayed Return to Usual Health Among Outpatients with COVID-19 in a Multistate Health Care Systems Network — United States, March–June 2020. MMWR Morb Mortal Wkly Rep 2020;69:993-998. DOI: http://dx.doi.org/10.15585/mmwr.mm6930e1
Week of July 13th through July 20th
In COVID-19 news this week, the CDC has revised the quarantine duration for patients with the disease, inhaled interferon shows promise, but data is very limited, transmission from older children is not uncommon and myocarditis is common among those with COVID-19 but the long term sequelae in survivors seem minor. Finally, hydroxychloroquine still doesn’t work.
Based on testing data, the CDC has determined that, except in rare cases (severe disease, immunosuppressed), the SARS-CoV-2 virus is no longer infectious 10 days after the onset of symptoms in patients with mild illness. Accordingly, the duration of quarantine for symptomatic individuals has been reduced to 10 days after symptom onset from the current 14 days as long as the patient is afebrile for 24 hours without the use of fever reducing drugs. Note that this does not change the length of quarantine for exposed individuals. Isolation is still 14 days after exposure.
Other points of note:
- A test-based strategy for leaving quarantine is no longer recommended (though can be used if needed to end quarantine in less than 10 days).
- Serologic testing should not be used to determine the presence or absence of SARS-CoV-2.
- PCR should not be done within the first 90 days of a previous positive. It likely represents viral RNA shedding and not new infection.
Inhaled interferon shows promise in reducing the severity of COVID-19 but we do not yet have published data. This randomized, controlled trial of a proprietary inhaled interferon with a planned 400 patients was stopped early after 101 patients were enrolled. The combined endpoint of death and need for mechanical ventilation was lower in those getting inhaled interferon. It isn’t clear from the press release that mortality was statistically better in the treatment group. The limited press release is not enough to push us to change our current practice.
Household transmission of SARS-CoV-2 from those aged 10-19 is more likely than from other age groups (although household transmission is less likely from those 0-9 years of age).
This is a study from Korea of 59,000 contacts of 5700 COVID-19 patients looking at positivity rates among contacts. Within households, there was an 11.8% COVID-19 positive rate overall (somewhat reassuring itself). The authors broke down household contacts by age. The index patient was 10-19 years old (124 individuals) in 18.6% (95% CI 14.0%–24.0%) of the families. Positive rate in families with an index case age 0-9 (29 individuals) was only 5.3% (95% CI 1 1.3%–13.7.0%). They do note that as more children are exposed when returning to school, their role in transmission will likely increase simply because of the increased number of exposures and positives in children. And, the numbers are still small in the 0-9 year age group.
Park YJ et al. Contact tracing during coronavirus disease outbreak, South Korea, 2020. Emerg Infect Dis. 2020 Oct (early release) https://doi.org/10.3201/eid2610.201315
The majority of hospitalized patients with COVID-19 have an elevated high sensitivity troponin T. Some patients have myocarditis but a preserved ejection fraction after discharge.
This is a series of 828 patients discharged from a single hospital in Britain. Seventy-one percent had an elevate high-sensitivity troponin-T (hsTnT) of which 41% died (compared to 8% of those without an elevated hsTnT). They excluded patients with PE or a history of ACS or another reason for an elevated troponin. A complete evaluation including cardiac MRI was only done on 29 patients (4%). Of these 29, 69% had “residual lung parenchymal changes”. Findings suggestive of myocarditis were seen in 45% of the 29. The mean left ventricular ejection fraction was normal, however (68%).
Unfortunately, even though they started with 828 patients in their series, only 4% had a complete workup after excluding known causes of an elevated hsTnT (which is clearly a marker for overall higher mortality). In those with presumed COVID-19 related myocarditis, the ejection fraction and wall motion were normal. There were some residual lung parenchymal changes but the clinical significance is not clear. It is hard to know what to do with this data at this point. Longer term follow-up will tell if there is any clinical significance to these findings.
Knight DS et al. COVID-19: Myocardial injury in survivors. Circulation 2020 Jul 14; [e-pub]. (https://doi.org/10.1161/CIRCULATIONAHA.120.049252)
Finally, hydroxychloroquine still doesn’t work.
This is a randomized, multicenter open label study of consecutive patients admitted for presumed COVID-19 less than 14 days after symptom onset (667 patients were enrolled but only 504 patients were found to be COVID-19 positive. Exclusion criteria included the need for > 4L of oxygen or use of study drug/macrolide for >24 hours before enrollment. Five-hundred and four patients were randomized 1:1:1 to get standard care alone, or plus hydroxychloroquine, or hydroxychloroquine + azithromycin. Treatment was continued for 7 days.
There was no difference in any outcome between the groups including death, discharge, need for oxygen, continued limits on activities after discharge, etc.
We already have data that hydroxychloroquine does not work for severe COVID-19 disease. We now have data that it does not work for mild-moderate disease requiring hospitalization. This also tells us that if it walks like a duck and quacks like a duck it is a house wren. A significant percentage of the patients enrolled for presumed COVID-19 did not test positive. Remember the “normal” diseases when seeing a patient with symptoms and signs that may be attributable to COVID-19.
Cavlacanti, AB et al. J Hydroxychloroquine with or without Azithromycin in Mild-to-Moderate Covid-19. NEJM July 23, 2020 DOI: 10.1056/NEJMoa2019014
Week of July 12th through July 19th
A lot of new and useful information about COVID-19 this week. We will cover neuropsychiatric manifestations of COVID-19, sequelae of COVID-19, how children fit (or don’t fit) into the epidemiology of transmission and some new information on mortality. Finally, we have additional data on COVID-19 in pregnancy.
Neurologic and psychiatric manifestations of COVID-19. The first study is a report of 153 patients collected online by several British neurological and psychological professional associations from April 1st -April 26th 2020; complete data was available for 125.
The neurologic manifestations of COVID-19 were protean including 62% of the 125 patients having a cerebrovascular event, (mostly ischemic but some hemorrhagic and a single vasculitis). Mental status changes were seen in 31%. Of this 31%, 23% were encephalopathic, 18% had encephalitis and 59% had a new neuropsychiatric diagnosis, such as psychosis, neurocognitive syndrome/dementia, or affective disorders. The great majority of diagnoses were confirmed or “probable”. About 50% of those with mental status changes were under 60. The great majority with CVA (82%) were over 60.
Likely, the psychiatric/neurologic diagnosis was dependent at least to some degree on the qualifications of the reporter (psychiatrist versus neurologist). Additionally, this does not give us a good denominator: these may be relatively rare events since reporting was selective. However, it does give us an idea of what we might think about when we see a COVID-19 patient with neurological or psychiatric manifestation.
- Varatharaj A et al. Neurological and neuropsychiatric complications of COVID-19 in 153 patients: A UK-wide surveillance study. Lancet Psychiatry 2020 Jun 25; [e-pub]. (https://doi.org/10.1016/S2215-0366(20)30287-X)
When COVID-19 “gets better” they don't become asymptomatic. This is a report of 143 patients who were followed up as outpatients after their acute COVID-19 hospitalization. Individuals ranged from 19-84 years of age with a mean of 57. 37% were women and all of the patients tested negative for COVID-19 at follow-up. Patients were evaluated a mean of 60 days after the onset of COVID-19 symptoms.
Only 13% reported no symptoms; 32% had one or two symptoms while 55% had 3 or more symptoms. Specifically, 53% reported fatigue, 43% continued dyspnea, 27% reported arthralgias and 22% reported “chest pain”. Less common symptoms included cough, anosmia, SICCA syndrome, headache, vertigo and others. About 45% reported a diminished quality of life.
This reminds us that COVID-19 symptomatology does not end when the patient is discharged from the hospital. It doesn’t give us information about interventions that might help or overall incidence (there were over 81,000 cases in the region) but does help us understand some of the medium-term sequelae of COVID-19.
- Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19 JAMA. Published online July 9, 2020. doi:10.1001/jama.2020.12603
Children may (or may not) be a source of contagion. One of the critical questions regarding COVID-19 in the Northern Hemisphere is whether to send children back to school after the summer break. We now have some data about infectivity among children.
This is a study of all children with COVID-19 infection < 16 years of age identified by the Geneva University Hospital in Switzerland. They tried to determine how often children were the index case in the family; 39 patients were followed. The great majority of pediatric patients presented with couth (82%), fever (67%) or nasal discharge (64%) followed by headache, sore throat and dyspnea. Almost all had mild symptoms They found that 8% of the time the child was the index case in the family.
This study has been cited to suggest that children are unlikely to represent a large source of infection. Not so fast. The numbers are limited. And, we don’t’ know how many children were exposed to COVID-19 outside of the home. It is possible that children were quarantined more frequently than adults (who may have had to go to work, etc.). For that reason, we cannot really draw firm conclusions about the infectivity of children with COVID-19.
- Posfay-Barbe KM, Wagner N, Gauthey M, et al. COVID-19 in Children and the Dynamics of Infection in Families. Pediatrics. 2020;146(2):e20201576
Mortality due to COVID-19 seems to be higher than is reported. Between March 1st and May 30th there were 780,975 reported deaths in the United States. This is 122,300 more deaths than predicted based on historical data. Of these excess deaths, about 95,500 were reportedly due to COVID-19. This leaves about 26,800 unexplained deaths suggesting about an undercount of approximately 22% of deahs do to COVID-19. Likely, this reflects inadequate testing: Patients are dying of COVID-19 but there is no documentation because of a dearth of testing.
- Weinberger DM et al. Estimation of excess deaths associated with the COVID-19 pandemic in the United States, March to May 2020. JAMA Intern Med 2020 Jul 1; [e-pub]. (https://doi.org/10.1001/jamainternmed.2020.3391
Finally, some additional data about COVID-19 and pregnancy. This study reports surveillance data of 91,000 US women age 14-11 with COVID-19 of whom 8200 were pregnant. Unfortunately, only 62% of pregnant women had symptom status reported versus 90% of those not pregnant. And, 75% of women did not report pregnancy status at all. Of those supplying data, about 97% of both groups were symptomatic. Cough and dyspnea were equally common in those pregnant and those not. Fever was less common during pregnancy, as were myalgias, chills, and diarrhea. Women who were pregnant were more likely to be admitted to the hospital (32% versus 6%), perhaps reflecting an abundance of caution. There were more ICU admissions and intubations in the pregnant group, however mortality was the same in both groups despite more diabetes, chronic lung disease and cardiovascular disease in the pregnant cohort.
A second study in of 241 pregnancies in New York found that a maternal BMI ≥30 kg/m2 was the sole factor associated with the severity of maternal disease (not underlaying illness, ethnicity, etc.) and that the severity of maternal disease was associated with preterm delivery. 6 of 236 (3%) of neonates tested positive for COVID-19.
This reminds us to be vigilant during pregnancy. While it is reassuring that COVID-19 related mortality is no worse in pregnancy, the need for inpatient intervention seems to be higher. Maternal BMI ≥30 seems to be one of the most important maternal factors in predicting the severity of disease. Both studies were consistent in finding that underlaying illness was not a predictor of severity (perhaps because immune changes in pregnancy trump underlaying illness). As in most things COVID-19, we need more and better data.
- Ellington S et al. Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status — United States, January 22–June 7, 2020. MMWR Morb Mortal Wkly Rep 2020 Jun 26; 69:769. (https://doi.org/10.15585/mmwr .mm6925a1)
- Khoury R et al. Characteristics and outcomes of 241 births to women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection at five New York City medical centers. Obstet Gynecol 2020 Jun 16; [e-pub]. (https://doi.org/10.1097/aog.0000000000004025)
Week of July 4th through July 11th
This has been a week in which we are seeing the rapid spread of COVID-19 in the US population. Below we will discuss COVID-19 transmission amongst meat packing workers, the seropositive rate in Spain and New York and the increase of abusive head trauma in children.
Reports of suspected abusive pediatric head trauma increased exponentially during the first month that the COVID-19 lockdown was in force in Britain.
This group looked at suspected abusive pediatric head trauma at one institution in Britain during the first month of COVID-19 lockdown. They compared this rate to the rate in the same months (23 March-23 April) in the 3 years preceding. All patients had a complete workup for abuse including MRI and/or CT. They found 10 cases in one month during lockdown compared to 0.67 cases/month at baseline. Of the abused children, 50% had colic. Unfortunately, 40% were found to be apneic with a decreased level of consciousness.
They point out that all of the families were had stressors including financial, mental health, and a history of criminal behavior. However, this may be a reflection of the area in which the hospital is located and doesn’t absolve other populations of similar problems with child abuse during lockdown.
This reminds us that the lockdown has been stressful leading to increased child abuse. It is also a reminder to discuss alternative caretakers with all families and identify alternate care givers ahead of time should the stress at home become so great that there is a risk of child abuse. This discussion seems to be particularly important in families with a colicky child, which can be trying in the best of times.
Sidpra J, Abomeli D, Hameed B, et al. Arch Dis Child doi:10.1136/archdischild-2020-319872Accepted 24 June 2020
Herd immunity may (or may not) be possibility against SARS-CoV-2
Spain is one of the countries that has been most impacted by COVID-19. This study elucidates the seropositive rate in the country. 36,000 households were contacted of which 75% agreed to have a point-of-care antibody test which, if a blood draw was allowed, was confirmed by chemiluminescent microparticle assay. A total of 61,000 individuals agreed to participate. The overall seropositive was 5% (95% CI 4.7-5.4) with higher rates around Madrid (10%) and lower results elsewhere in the country. There are several concerns about this study including the validity of a point of care antibody testing. However, if these results are confirmed, it speaks against the possibility of rapid herd immunity: it is estimated that at least 60% of the population need to be immune in order to have herd immunity.
Alternatively, in a predominately minority neighborhood up to 68% of patients seen at one clinic in Queens, New York were seropositive vs. 13% in a more affluent, White, area. This likely overestimates the positivity rate because of selection bias; those symptomatic were probably more likely to get the test. But it also speaks to the disproportionate burden of disease in people of color. As with most of COVID-19, we need more, and better, data.
Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study Published:July 06, 2020DOI:https://doi.org/10.1016/S0140-6736(20)31483-5
Meat processing plants seem to be particularly prone to outbreaks of COVID-19 infection amongst workers.
The CDC has tried to quantify the toll of COVID-19 on workers in the 3,5000 US meat processing plants. This data was collected in April and May of 2020. Only 28 of 50 states responded of which 23 states reported COVID-19 outbreaks in meat processing plants. Of those states reporting, there were 16,233 cases with 86 deaths. Minorities represented 87% of the cases, reflecting the burden of COVIED-19 illness in minority populations. The report notes that social distancing is difficult in this environment. Only 111 (of 3500 plants nationally) reported what steps they had taken to protect workers. 22% closed operations. Only 37% offered COVID-19 testing to employees. At least in Iowa (where I live) there is no requirement to report workplace outbreaks. Without mandatory reporting, it will be difficult to get a handle on the impact of COVID-19 on workplaces.
Wlaltenburg MA, Victoroff T, Rose CE, et al. Update: COVID-19 Among Workers in Meat and Poultry Processing Facilities ― United States, April–May 2020. MMWR Morb Mortal Wkly Rep. ePub: 7 July 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6927e2external icon.
Week of June 28th through July 3rd
Welcome to the weekly update. This week we have an updated guideline for the use of masks issued by the CDC, more information about Multisystem Inflammatory Syndrome in Children, a quantification of the stroke risk in COVID-19 patients admitted/ED, as well as a quick report on the effect of the pandemic on exercise.
The CDC has released guidelines calling for the use of cloth masks in public.They point out that masks should be used except in “children under the age of 2 or anyone who as trouble breathing, is unconscious, incapacitated or cannot remove the mask without assistance.”
The information at both sites is appropriate for all audiences, however.
We have new information on Multisystem Inflammatory Syndrome in Children (MIS-C)
As a quick review, the case definition of MIS-C is (verbatim from the CDC):
- An individual aged <21 years presenting with fever*, laboratory evidence of inflammation**, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND
- No alternative plausible diagnoses; AND
- Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or exposure to a suspected or confirmed COVID-19 case within the 4 weeks prior to the onset of sym
*Fever >38.0°C for ≥24 hours, or report of subjective fever lasting ≥24 hours
**Including, but not limited to, one or more of the following: an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes and low albumin.
The first report is of a series of 95 confirmed and 4 suspected cases in the State of New York. The second case series of 186 individuals confirms the findings of the first (albeit with slightly different percentages). Overall, the presentation of MIS-C occurred 10-31 days after the onset of COVID-19 symptoms with a median of 21 days.
Patients of color were over-represented in the group with MIS-C; 40% were Black and 36% Hispanic. About ½ were male and “children” of all ages were represented: age 0-5 (31%), 6-12 (42%) with the remainder being 13-20 years of age. Many had underlaying conditions (36% overall, primarily obesity but also chronic lung disease). All patients had fever or chills with 97% having tachycardia, 80% with GI symptoms, 60% with rash, 56% had conjunctival injection and 27% showed mucosal changes. 53% had evidence of myocarditis and 2 died.
In both series, a diagnosis of Kawasaki’s disease or incomplete Kawasaki’s disease was given in about 39% with approximately 9% having coronary artery aneurysms. Treatments varied so cannot be commented on. This reminds us to be on the lookout for MIS-C and not to assume that it will be present at the first encounter for COVID-19.
Dufort, EM. et al. Multisystem Inflammatory Syndrome in Children in New York State. NEJM 29 June 2020 DOI: 10.1056/NEJMoa2021756
Feldstein, LR. et al. Multisystem Inflammatory Syndrome in U.S. Children and Adolescents NEJM June 29, 2020 DOI: 10.1056/NEJMoa2021680
Stroke risk is elevated in those with COVID-19 who are seen in an ED or admitted compared to those who have influenza.
We have had anecdotal evidence of an elevated stroke risk with COVID-19. We now have some data about 1961 COVID-19 patients and 1486 control patients with influenza seen in the ED or admitted to an inpatient unit. Stroke was determined by a panel of neurologists reviewing the chart; not all stroke patients had imaging which is one weakness of this study. Of those with COVID-19, 1.3% (CI 95 % 1.1%-2.3%) were diagnosed with a stroke compared to 0.2% (CI 95% 0.0%-0.6%.) of those with influenza. This difference remained after adjusting for age, gender and, vascular risk factors and “race” with an odds ratio of 7.6 (CI 95% 2.3-25.2). It is likely that some confounders remain such as smoking. What we do with this information in terms of prophylaxis is yet undetermined.
Merkler, AE et al. Risk of Ischemic Stroke in Patients with COVID-19 versus Patients with Influenza. JAMA Neurol. Published online July 2, 2020. doi:10.1001/jamaneurol.2020.2730
In a brilliant little study documenting step counts, it was found that exercise (as measured by step counts) was reduced by 7% in Sweden and 49% in Italy 30 days into the pandemic.
This study tracked step counts based on smartphone fitness app Argus (a product of Azumio corporation). It tracked 455,404 unique users from 187 unique countries. The mean decrease of steps was 27% per day at 30 days after the announcement of the pandemic with regional variation as noted above.
Of course this is not a randomized study and only looked at people owning a cell phone who use the Argus app. It is a good reminder to clinicians, however, to help patients come up with alternative ways to maintain exercise and fitness during the pandemic.
Tison, GH et al. Worldwide Effect of COVID-19 on Physical Activity: A Descriptive Study 29 June 2020 Annals of Internal Medicine, https://www.acpjournals.org/doi/10.7326/M20-2665
Week of June 21st through June 27th
There have been several notable developments regarding COVD-19 over this past week. These include:
- The expansion of the “at risk” criteria by the CDC
- A warning from the FDA about the accuracy of multiple brands of antibody tests.
- The usefulness of even good antibody tests.
- New information about the survival of SARS-CoV-19 in aerosols.
- Finally, there were two unique ideas were published this week about 1) how to go about testing in low resource areas and 2) how to create an N-95 mask out of a regular surgical mask.
The CDC released a new list of individuals at-risk for severe illness with COVID-19. The high-risk criteria include:
- Advanced age
- Chronic kidney disease
- Immunocompromised state
- Obesity (BMI of >30); This is changed from the prior cutoff of a BMI of 40
- “Serious conditions” such as heart failure, CAD, cardiomyopathy
- Diabetes Mellitus type 2
- Sickle cell disease
- Children with congenital heart disease or neurologic or genetic diseases, including inborn errors of metabolism.
A second list of individuals who “might be at increased risk” for severe illness with COVID-19 per the CDC include those with:
- Cerebrovascular disease
- Cystic fibrosis
- Neurologic conditions such as dementia
- Liver disease
- Pulmonary fibrosis
- A significant history of smoking
- Diabetes Mellitus type 1
Pregnancy is a reversal from the previous dictum that COVID-19 risk was not elevated in pregnancy. Additional data on pregnancy now classifies it as a high-risk condition. A CDC study of 8207 patients found that 1) presenting symptoms are the same as in the non-pregnant population, 2) Risk of admission and ventilation is increased in those who are pregnant, but mortality rate is not. In this study, 32% of pregnant women were admitted to the hospital compared to 5.2% of non-pregnant women. Part of this may be because of an abundance of caution in treating women who are pregnant, especially since mortality doesn’t differ. None-the-less we know that pregnancy is a relatively immunodeficient state with reduced T4 cells, among other changes.
Ellington S, et.al. Strid P, Tong VT, et al. Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–June 7, 2020. MMWR Morb Mortal Wkly Rep 2020;69:769–775. DOI: http://dx.doi.org/10.15585/mmwr.mm6925a1external icon.
The FDA sent out a warning about the accuracy of multiple brands of antibody tests for COVID. The list is extensive and can be found here under the heading “What Tests Should No Longer Be Distributed for COVID-19?”
We also have additional information from an analysis by the Cochrane group about the clinical usefulness of IgG/IgM tests for SARS-CoV-19. After looking at the literature on enzyme‐linked immunosorbent assays, chemiluminescence immunoassays, and lateral flow assays tests they found that:
- Tests were positive
- Only 30% of the time during the first week of illness
- 72% of the time day 8 of illness to day 14 of illness
- 92% of the time day 15 to 21
- Data beyond 21 days was not considered reliable.
This emphasizes the limited use of these tests in diagnosing acute infection. Nasal swab PCR remains the test of choice.
Antibody tests for identification of current and past infection with SARS‐CoV‐2 Cochrane Systematic Review -Version published: 25 June 2020 https://doi.org/10.1002/14651858.CD013652
SARS-CoV-2 remains infectious in aerosols for at least 16 hours.
This is an early release article by the CDC. These investigators nebulized SARS-CoV-2 and measured the infectivity as far out as 16 hours. They found that SARS-CoV-2 remains infectious in suspended aerosols for at least 16 hours (at which point they stopped testing). This has implications for contact tracing. One may have been exposed to SARS-Co-V-2 long after the index case left the area. How this will change practice remains to be seen.
Fears SC, Klimstra WB, et al. Persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions. Emerg Infect Dis. (publication date online: 25 June 2020)
It is possible to pool patient samples and run a single test in low resource areas.
These authors model a unique solution to the lack of adequate PCR tests. They suggest pooling the tests of several patients and running them as a single sample. If the test is negative, you are done. If the test is positive, each individual needs to be tested separately. They present several scenarios. For example, if the PCR is 70% sensitive and there is a 1% positive rate, 13 patients could be tested as one sample. In this case, only 16% of the number of tests would be needed compared to if each patient was initially tested separately. They present several scenarios in their analysis. This is not ready for prime time but is an example of a unique solution when there may be limited reagents, etc. Of course, you still do need one swab per person.
Finally, how do you make a typical surgical mask into an N95 mask? Just add rubber-bands.
These authors point out that surgical masks are N95 masks in terms of particle permeability. The main issue is that surgical masks leak leading to inhaling non-filtered air. They propose two solutions: one using rubber-bands and the other using a rubber sheet (think inner tube from a truck tire). In limited testing, these modified surgical masks were found to be as good as N95 masks at filtering the inhaled air. These are not yet approved as an official solution, but they have applied for CDC/NIOSH certification.
Instructions for making the masks is here: https://www.fixthemask.com/make-it
Week of June 14th through June 20th
This week we have results from the “long awaited” (in COVID-19 time) randomized trials of hydroxychloroquine and dexamethasone for treatment of COVID-19 as well as new guidelines from the CDC for testing. We also have new information on the safety of convalescent plasma in treating COVID-19. Note that the hydroxychloroquine and dexamethasone trials have not yet been peer reviewed but the protocol, data, etc. are available online here.
1) Hydroxychloroquine does not work for hospitalized patients. We already know that hydroxychloroquine does not work to prevent infection. We now have information that it doesn’t work to treat COVID-19. This is a randomized, controlled trial of 11,000 plus hospitalized COVID-19 patients in the United Kingdom. (the “RECOVERY” trial). Within this study, 1542 patients were randomized to hydroxychloroquine and 3132 got usual care without hydroxychloroquine. The endpoint was mortality at 28 days. There was no difference in mortality (25.7% with hydroxychloroquine and 23.5% with standard care (hazard ratio 1.11 [95% confidence interval 0.98-1.26]). There was also no difference in hospital stay or other endpoints. Read more here.
In addition to this negative study, there are concerns that hydroxychloroquine may reduce the antiviral activity of remdesivir (more here). Given the preponderance of data, the FDA in the US has revoked the authorization to use hydroxychloroquine for COVID-19 (more here). There is now good evidence that hydroxychloroquine should not be used for treating COVID-19 in any clinical setting.
- A Randomized Trial of Hydroxychloroquine as Postexposure Prophylaxis for Covid-19 NEJM. June 3, 2020 DOI: 10.1056/NEJMoa2016638
2) Dexamethasone is the first drug to reduce mortality in patients with COVID-19 who require respiratory support. This is an analysis of another arm of the “RECOVERY” trial. In this arm, 2104 patients were randomized to dexamethasone 6mg once a day for 10 days and were compared to 4321 patients randomized to usual care alone. The 8-day mortality was highest in those who required ventilation (41%), lower in those patients who required oxygen only (25%), and lowest among those who did not require any respiratory support (13%). The NNT to prevent one death in patients on a ventilator is 8. The NNT for patients treated with oxygen alone (non-invasively) is 25. Patients who did not require oxygen did not benefit.
To put this in perspective, the numbers have been reported as “a miracle” with a reduction of death of 1/3 in ventilated patients and 1/5 of those on non-invasive oxygen. But those are relative reductions and not absolute reductions in mortality. The NNT is a better measure of the absolute reduction in mortality. Still a positive outcome, but certainly not a “a miracle” cure.
The results of this study are in contrast to the recommendations not to use steroids in COVID-19. It reminds us that “expert opinion” can be wrong and a well conducted study can change practice. The same shift has occurred with hydroxychloroquine: “Expert opinion” suggested using it, well controlled studies have shown there is no benefit.
3) Convalescent plasma is safe when used to treat COVID-19 although we still do not have solid data on efficacy.The first study is a retrospective analysis of 5000 hospitalized patients who got convalescent plasma therapy. Sixty-six percent of the patients were in the ICU. Overall 7-day mortality was 14.9% with a mortality of 0.3% within 4 hours of plasma infusion. This is consistent with the expected mortality based on historical data (10-20%). Adverse events were rare and there was no signal suggesting convalescent plasma is harmful. They report 4 deaths, transfusion associated fluid overload (TACO) in 7 patients, transfusion related lung injury in 11 patients and severe allergic reaction in 4.
A second study of 25 patients treated at Huston Methodist hospitals came to a similar conclusion regarding the safety of convalescent plasma.
- J Clin Invest. June 11, 2020. https://doi.org/10.1172/JCI140200. (https://www.jci.org/articles/view/140200/pdf)
- Am J Pathol 2020,-:1e11;https://doi.org/10.1016/j.ajpath.2020.05.014
4) There is a new, comprehensive summary statement about testing released by the CDC. The full document is here. A brief summary:
- Antibody testing is not to be used for diagnosing an acute infection.
- An authorized PCR or antigen detection assay should be used to test patients with symptoms.
- Asymptomatic patients with known or suspected exposure to COVID-19 should be tested, hopefully as part of a contact tracing program.
- For those asymptomatic individuals without known exposure in special settings such as group homes or nursing homes there are several recommended options. These include(verbatim):
Approaches for early identification of asymptomatic individuals include:
- Initial testing of everyone residing and/or working in the setting,
- Regular (e.g., weekly) testing of everyone residing and/or working in the setting, and
- Testing of new entrants into the setting and/or those re-entering after a prolonged absence (e.g., one or more days)
Settings for which these approaches could be considered include:
- Long-term care facilities
- Correctional and detention facilities
- Homeless shelters
- Other congregate work or living settings including mass care, temporary shelters, assisted living facilities, and group homes for individuals with intellectual disabilities and developmental disabilities
- High-density critical infrastructure workplaces where continuity of operations is a high priority
The bottom line is that this is a comprehensive, complex document that can be found here.
Week of June 7th through June 13th
It has been a relatively quiet week in COVID-19. Mostly, our knowledge is more uncertain with the withdrawal of several large studies (see below)
1) The CDC has published illuminating information about the outbreak of COVID-19 on the aircraft carrier USS Theodore Roosevelt. While a convenience sample and not a randomized study, it is still instructive. Among the most important points:
- Those who practiced prevention had a lower rate of COVID-19 infection (e.g., wearing a face covering, 55.8% versus 80.8%; avoiding common areas, 53.8% versus 67.5%; and observing social distancing, 54.7% versus 70.0%, respectively).
- 60% of individuals had neutralizing antibodies after infection (which is stated as being a positive although it also means that 40% do not have neutralizing antibodies.)
- 20% of infected patients were asymptomatic.
- Loss of taste (ageusia) and anosmia were particularly strongly associated with COVID-19 infection (OR 10.3).
Payne DC, et al. SARS-CoV-2 Infections and Serologic Responses from a Sample of U.S. Navy Service Members — USS Theodore Roosevelt, April 2020. MMWR Morb Mortal Wkly Rep. ePub: 9 June 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6923e4external icon.
2) Studies withdrawn
Two large studies were withdrawn because of an inability to independently confirm the veracity of their databases. A third study was withdrawn because of methodologic problems. These studies are:
- Mehra MR et al., “Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19,” published in the New England Journal of Medicine: This paper looked at the safety of ARBS and ACE-I and suggested no detriment in those infected with COVID-19. We still don’t know the answer.
Mehra MR et al., Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis. Published in The Lancet. This paper suggested that hydroxychloroquine and chloroquine were harmful in those ill with COVID-19. We still don’t have an answer.
You can read more here: BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2279 (Published 09 June 2020) BMJ 2020;369:m2279
- “Effectiveness of Surgical and Cotton Masks in Blocking SARS-CoV-2. A Controlled Comparison in 4 Patients”. This paper suggesting that surgical and cotton masks do not work was withdrawn because of methodological problems. We do have other good studies suggesting masks do work (see above, for example). https://www.acpjournals.org/doi/10.7326/L20-0745
Week of May 31st through June 6th
Six new advances in COVID-19 the week of May 31st through June 6th.
1) Finding a positive PCR after infection does not necessarily reflect infectivity. Numerous studies have found patients with a positive PCR for SARS-CoV-2 after recovery from clinical illness. The question has been, “Does this reflect infectivity?” There is now data suggesting that the answer is not necessarily. This is a retrospective study of 92 PCR positive samples which were submitted for culture. Overall, 29% of cultures were positive for SARS-CoV-2. However, no cultures were positive in those with a symptom onset > 8 days before the PCR or a RT-PCR cycle threshold (Ct) of >24 (the number of cycles of amplification before detection, with a Ct of > 24 being is a strong reaction suggesting a large amount of SARS-CoV-2 nucleic acids). The study concluded that the infectivity of patients with Ct >24 (e.g. even some of those with a large amount of viral RNA) and/or a duration of symptoms >8 days may be low.
It is reassuring that not all patients with a positive PCR after COVID-19 are infectious and that at 8 days after symptom onset none were culture positive. More information is needed on this topic to make definitive claims.
Accepted prepublication manuscript: Clinical Infectious Diseases, ciaa638, https://doi.org/10.1093/cid/ciaa638 Published: 22 May 2020e
2) Post-exposure prophylaxis does not seem to reduce the occurrence of symptomatic COVID-19.
This is a randomized, double blind, placebo-controlled trial of hydroxychloroquine in the prevention of COVID-19. The study included 821 individuals who were exposed to a known COVID-19 case. Exposure was defined as an occupational or household exposure within 6 feet for at least 10 minutes without the use of protective equipment (high risk, 719 participants) or with a mask but no eye protection (moderate risk, 108 participants). Participants were randomized to hydroxychloroquine 800mg followed by 600mg in 6-8 hours, then 600mg for 4 days) within 4 days of exposure. The outcome was laboratory confirmed COVID-19 or symptoms consistent with COVID-19.
There was no difference in the infection rate between the two groups (11.8% vs. 14.3% (difference of 2.5% CI 95 -7.0-2.2)). Discontinuation was significantly higher in the hydroxychloroquine group (75% compliance in hydroxychloroquine group vs. 83% in the placebo group). Side effects were reported by 40% of the active treatment group vs. 17% of the placebo group.
This study shows no benefit to hydroxychloroquine in reducing infection after a COVID-19 exposure. The weakness of this study is that it relied partly on participant symptom report and not all infections were verified by PCR. Additionally, it does not tell us about the rate of asymptomatic infection. There are ongoing studies of pre-exposure prophylaxis including a large study in health care workers.
NEJM June 3, 2020 DOI: 10.1056/NEJMoa2016638
3) We still don’t have an answer on convalescent plasma.
Anecdotal reports suggest that convalescent plasma therapy in patients with severe COVID-19 may be beneficial. The results of an open label, randomized trial of 103 select patients with life threatening COVID-19 who all got standard care with 52 getting convalescent plasma added to their regimen was released. There were multiple exclusion criteria.
Looking only at mortality, there was a non-statistically significant benefit to convalescent plasma (mortality 15.7% versus 24.0% 95% CI 0.29-1.46).
Why is an 8% difference not significant? The study was underpowered to find a difference. The study was designed to include 200 patients and only enrolled 103. This is called a “Type II error”. You can remember this by the mnemonic that in a type II error there are “too few” participants to find a difference that actually exists. This study suggests a difference, but more data is needed to make a definitive conclusion.
JAMA. Published online June 3, 2020. doi:10.1001/jama.2020.10044
4) A plea to treat air hunger in those with COVID-19 related ARDS who need intubation.
This pre-publication commentary reminds us to treat air hunger in those who are intubated and receiving low tidal volume ventilation. Low tidal volume ventilation leads to “permissive hypercapnia” with an increase in pCO2. This leads to a sensation of air hunger, which in other studies, is associated with psychological trauma leading to PTSD in some survivors of ARDS. The authors of this study point out that this is the same mechanism that is operative in torture (e.g. waterboarding). They make several points, including:
- Include narcotics in the initial sedation protocol and continued sedation management of intubated patients. Morphine 5mg IV has been shown to be very effective at reducing air hunger.
- Benzodiazepines do not reduce air hunger although they may reduce the resultant psychological trauma.
- Paralysis alone does not reduce air hunger, contrary to popular belief. It should also be noted that patients should not be paralyzed until they are fully sedated. While paralyzed, sedatives should not be weaned. Institutional protocols for paralysis should be followed.
5) Masks, Social Distancing or Both?
Adoption of social distancing and masks has not been universal at least partly because of the belief that these measures do not help reduce COVID-19 transmission. This study questions that rationale.
This is a systematic review and meta-analysis of 172 studies looking at transmission of coronaviruses (specifically COVID-19 but also SARS and MERS). All studies were ranked using Cochrane and GRADE methods. Forty-four studies met quality criteria and were included in the meta-analysis (a total of 25,697 patients). None were randomized controlled trials.
Social distancing of at least one meter was associated with a 10.2% reduction in transmission (CI 11.5 to 7.5) (n=10,736). The risk of transmission decreased by a relative risk of 2 per additional meter-distance (moderate certainty). Masks (n=2647), had a large effect on transmission with a risk difference of 14.3%. As one would expect, N95 masks performed better than disposable surgical masks or those with 12-16 layers of cotton (low certainty). Eye protection (n=3713) also reduced transmission (10.6%-low certainty). Subgroup and sensitivity analyses lead to the same conclusion.
It isn’t likely that a randomized trial of masks will be done given the ethical implications of knowingly exposing patients to a potentially fatal virus. The best data to date reinforces the directives to maintain social distancing and to wear masks to prevent disease transmission.
The Lancet June 1, 2020 https://doi.org/10.1016/S0140-6736(20)31142-9
6) And, as one might expect, even more stringent precautions work better.
This is an MMWR report on the results of stringent measures to reduce COVID-19 transmission in a high-density military population of 10,579 trainees. Steps taken include:
- Quarantine for 2 weeks upon arrival
- Social distancing of at least 6 feet
- Testing if the individual had symptoms
- The use of cloth masks
- Travel restrictions on those wanting to enter the base
Using these techniques, they were able to limit transmission to a total of 5 cases of whom 3 were contacts of the first case. The spread was extrapolated to be 47/100,000 people.
How this applies to the general public is not known. Military bases are a very structured and closed environment and behavior can be mandated unlike in the general population.
Marcus JE, Frankel DN, Pawlak MT, et al. COVID-19 Monitoring and Response Among U.S. Air Force Basic Military Trainees — Texas, March–April 2020. MMWR Morb Mortal Wkly Rep. ePub: 2 June 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6922e2external icon.
Week of May 24th through May 30th
Four clinically relevant updates for the past week
1) Even mildly symptomatic infections with SARS-CoV-2 leads to an antibody response.
One of the many unanswered questions about COVID-19 is the robustness of the immune response in patients who experienced only mild symptoms. This was a study of 160 hospital staff in Strasbourg, France who were symptomatic with PCR proven COVID-19 but who did not require hospitalization. Blood was drawn a median of 24 days after the onset of COVID-19 symptoms. Overall, 99.4% of patients had anti-SARS-CoV-2 antibodies. The percent of samples with neutralizing antibodies was 79%, 92% and 98% at 13-20, 21-27 and 28-41 days after symptom onset.
These findings indicate that serological testing for COVID-19 is a useful tool to determine who has had a previous symptomatic infection. Unfortunately, in the absence of serial blood draws, it is difficult to extrapolate the overall rate of neutralizing antibodies in the whole cohort at 41 days after symptom onset and how many who were negative at 13-20 days subsequently became positive for neutralizing antibodies. It is also presently unclear how protective these antibodies are.
MedRxiv (prepublication) doi: https://doi.org/10.1101/2020.05.19.20101832
2) The CDC has issued guidelines for antibody testing. Among the recommendations are:
- Using an FDA reviewed test.
- Using a test with a specificity of 99.5% or greater, as screening will likely result in a high level of false positives.
- Focusing on high risk individuals is more likely to be useful than mass screening.
- Being aware that testing for neutralizing antibodies has not yet been approved in the US.
- Being similarly aware that IgA testing is not recommended at this time (IgG and IgM testing are both available).
- Avoiding use of serologic test results to make decisions about who can return to work.
- Avoiding use of serologic tests “to make decisions about grouping persons residing in or being admitted to congregate settings, such as schools, dormitories, or correctional facilities.”
3) The results of the long-awaited remdesivir trial have been released; remdesivir seems to reduce the duration of illness in those hospitalized patients with mild illness. There was no mortality benefit observed in this study.
1063 patients with COVID-19 were randomized to either placebo or up to 10 days of remdesivir. The principle outcome was time to recovery, defined by either by discharge from the hospital or clinical recovery with continued hospitalization for isolation purposes only. The recovery time was 11 days in those getting remdesivir versus 15 days those getting placebo (p<0.001).
Unfortunately, there was no difference in mortality (hazard ratio for death, 0.70; 95% CI, 0.47 to 1.04). Additionally, the benefit was only seen in patients who were receiving low flow oxygen. Intubated patients, those requiring high flow oxygen and/or non-invasive ventilation and those not requiring oxygen did not benefit. Early treatment seems to be key in the use of remdesivir.
4) Another bad week for chloroquine/hydroxychloroquine and azithromycin
Individual studies have been negative for any benefit to chloroquine/hydroxychloroquine/azithromycin in hospitalized patients. Retrospective analysis is now available for 96,032 patients who were treated with chloroquine alone, chloroquine with a macrolide, hydroxychloroquine alone, or hydroxychloroquine with a macrolide. Attempts were made to control for factors such as cardiovascular disease, diabetes mellitus, age, lung disease and baseline severity. Of the patients, 1868 received chloroquine, 3783 received chloroquine with a macrolide, 3016 received hydroxychloroquine, and 6221 received hydroxychloroquine with a macrolide. The other 81,144 patients were in the control group.
The bottom line is that there was no benefit to drug treatment and an increase in mortality with treatment (control group 9·3% vs 16.4% in the chloroquine group and up to 24% mortality with hydroxychloroquine plus a macrolide).
WHO has stopped ongoing studies of these drugs based on this data. Until there is a controlled trial, these drugs should not be used for inpatient treatment as there is likely significant harm. It should be noted, however, that this was not a controlled trial and adjustment for comorbidities is always imprecise.
The Lancet. May 22, 2020DOI:https://doi.org/10.1016/S0140-6736(20)31180-6
Week of May 17th through May 23rd
More cases of a COVID-19 associated systemic inflammatory syndrome have been reported in children
The CDC has advised being on the lookout for the increasingly reported Multisystem Inflammatory Syndrome in Children (MIS-C). Any such cases should be reported to the CDC. The case definition (verbatim from the CDC) is as follows:
- An individual aged <21 years presenting with fever, laboratory evidence of inflammation, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND
- No alternative plausible diagnoses; AND
- Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms
- Fever >38.0°C for ≥24 hours, or report of subjective fever lasting ≥24 hours
- Including, but not limited to, one or more of the following: an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes and low albumin
- Additional Considerations (per CDC)
Some individuals may fulfill full or partial criteria for Kawasaki Disease, but should be reported if they meet the case definition for MIS-C.
Consider MIS-C in any pediatric death with evidence of SARS-CoV-2 infection
Additional information can be found here: Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19)
BCG vaccine does not seem to protect against COVID-19
There was some speculation early in the COVID-19 pandemic that patients were protected against COVID-19 if they had had bacille Calmette-Guerin (BCG) immunization against tuberculosis. Unfortunately, a new study seems to refute this.
This was a retrospective study of 3064 Israelis born between 1979-1981 who got BCG and 2869 born between the years of 1983 and 1985 who did not (after universal vaccine was halted). No difference in COVID-19 infection was found between the two groups (vaccinated: 11.7%, unvaccinated: 10.4%). The study was unable to measure the severity of disease vs. immunization status because there were few patients with severe illness in this cohort.
SARS-COV-2 Rates in BCG-Vaccinated and Unvaccinated Young Adults. JAMA. Published online May 13, 2020
Guillain-Barre Syndrome joins encephalopathy as an additional possible result of COVID-19
It is known that COVID-19 can cause an encephalopathy which can then take months to resolve. A new paper reports five cases of a Guillain-Barre-like syndrome occurring in relation to COVID-19.
This is a report from Italy of five patients with COVID-19 who had an associated Guillain-Barre syndrome. Of these five, four had onset presenting as lower limb weakness and facial diplegia. The syndrome progressed to include flaccid paralysis, but not dysautonomia. Cerebrospinal fluid (CSF) polymerase chain reaction (PCR) in all patients was negative for COVID-19. Electromyogram (EMG) showed axonal Guillain-Barre in three patients and demyelination in two. Treatment was with plasma exchange and intravenous immunoglobulin (IVIG). As with many other COVID-19 patients, three members of the study were placed on ventilation.
Toscano G et al. Guillain–Barré syndrome associated with SARS-CoV-2. N Engl J Med 2020 Apr 17; [e-pub]. (https://doi.org/10.1056/NEJMc2009191)
New Online Risk Calculator Available
A group out of China has developed a risk calculator for predicting the severity of illness in those with COVID-19. They initially observed 1,590 patients and found that 10 risk factors seem to change the outcome of those with COVID-19 (derivation set).
These risk factors include:
- X-ray Appearance
- Number of comorbidities (defined on the calculator link)
- History of cancer
- Neutrophil to lymphocyte ratio
- Lactate dehydrogenase (LDH)
- Direct bilirubin
The group then applied their rule to another 710 patients (validation set). Using this tool, the group was able to categorize patients as low, medium or high risk for progressive disease. The probability for adverse events (invasive ventilation/ICU admission/death) in the various groups is as follows: low-risk group 0.7% (e.g. 0.7% with a low risk score went on to have an adverse event); medium-risk score group 7.3% had an adverse event; high-risk group score 59.3% had an adverse event. The calculator can be found here.
JAMA Intern Med. Published online May 12, 2020. doi:10.1001/jamainternmed.2020.2033
Week of May 10th through May 16th
1) CDC Updates Guidelines for Discontinuing Isolation in Persons with COVID-19
For individuals recovered from COVID-19 illness, the CDC has increased the recommended period of isolation from 7 days to 10 days after illness onset and at least 3 days after recovery. The CDC defines illness onset as the date symptoms begin. Recovery is defined as resolution of fever without the use of fever-reducing medications with progressive improvement or resolution of other symptoms. Ideally, isolation should be maintained for this full period to the extent that it is practicable under rapidly changing circumstances.
2) COVID-Associated Coagulopathy
It is now clear from multiple studies that 10-43% of patients with COVID-19, especially those who are critically ill, are hypercoagulable. The exact number is not well elucidated. Studies differed with variations in severity of illness presentation among patients.
This hypercoagulability results in both arterial and venous thromboses. It has been known almost from the start of the epidemic that an elevated d-dimer in COVID-19 patients is a marker for poor outcomes since the d-dimer is a marker for ongoing thrombosis. The thrombotic complications seen in COVID-19 include deep vein thrombosis (DVT), pulmonary embolism (PE), stroke, acute coronary syndrome (ACS)/myocardial infarction (MI), limb ischemia and gastrointestinal (GI) ischemia. There are also reports of cardiac valve clots.
Patients with COVID-19 associated coagulopathy generally have normal clotting studies (aPTT, PT/INR) but may have an elevated aPTT reflecting an anticardiolipin antibody/lupus-like anticoagulant (90% in one series of those with an elevated aPTT). Unlike in disseminated intravascular coagulation (DIC), hypercoagulable COVID-19 patients often have normal or slightly high platelet counts and high fibrinogen. These patients are hypercoagulable despite the elevated aPTT and should be anticoagulated as per standard of care.
There is consensus that “all” patients admitted to the hospital should be treated with prophylactic-dose heparin (e.g. enoxaparin or others) and should have a low threshold for evaluation of blood clot (e.g. chest CT, extremity doppler, etc.). If a patient is deteriorating and CT for PE will be delayed, it is reasonable to start full anticoagulation while awaiting study results, balancing treatment with consideration of bleeding risk.
Some institutions are starting full-dose anticoagulation on critically ill patients without known clot, which remains controversial.
NEJM May 5, 2020 DOI: 10.1056/NEJMc2013656
Abdominal Visceral Infarction in 3 Patients with COVID-19 https://wwwnc.cdc.gov/eid/article/26/8/20-1161_article?deliveryName=USCDC_333-DM28184
Journal of Thrombosis and Heamostasis, https://onlinelibrary.wiley.com/doi/10.1111/jth.14888
3) In Vivo Human Monoclonal Antibodies
A study reported the discovery of human monoclonal antibodies that neutralize SARS-CoV-2 (and SARS-CoV) in cell culture. While there is currently no vaccine that can prevent the disease, this monoclonal antibody could potentially offer future prevention and treatment. This is not clinically available at present, but the finding indicates that effective neutralizing antibodies can be identified as they target a communal epitope on the virus, thus increasing the probability of an effective vaccine being identified.
Wrapp et al., Structural Basis for Potent Neutralization of Betacoronaviruses by Single-Domain Camelid Antibodies, Cell (2020), https://doi.org/10.1016/j.cell.2020.04.031
Wang, C., Li, W., Drabek, D. et al. A human monoclonal antibody blocking SARS-CoV-2 infection. Nat Commun 11, 2251 (2020). https://doi.org/10.1038/s41467-020-16256-y
4) Another bad week for hydroxychloroquine
Another week, another negative study of hydroxychloroquine in COVID-19. This is a study of 1446 consecutive patients admitted for COVID-19 excluding those who were intubated, died, or were discharged within 24 hours. Outcomes were intubation or death in a time-to-event analysis. Propensity scoring was used to adjust the data for disease severity, smoking, etc. They also did a multiple sensitivity analyses to test the robustness of their results. There was no difference between intubation plus death between the placebo and treatment groups (hazard ratio, 1.04, 95% confidence interval, 0.82 to 1.32).
NEJM May 7, 2020 DOI: 10.1056/NEJMoa2012410
Weeks of April 26th through May 9th
1) COVID-19 Disease and Kawasaki disease
Over the past week there have been several cases Kawasaki disease/an overlap syndrome of toxic shock and Kawasaki syndrome in children with COVID-19. Reports note fever, conjunctivitis, a polymorphous, blanching rash, tongue involvement and swelling of hands and feet.
The Pediatric Intensive Care Society from Britain has alerted providers to be vigilant in identifying these patients and note that they often have GI symptoms, abdominal pain, myocarditis and coronary artery findings consistent with Kawasaki Disease. Lab abnormalities include an elevated troponin, and elevated CRP and sedimentation rate. Of note, some of these patients have been COVID-19 negative.
Comment: The classic constellation of symptoms for Kawasaki disease include: Fever for at least 5 days, Mucositis, Conjunctivitis, Polymorphous rash, Distal extremity edema, and Lymphadenopathy (which is commonly absent). An incomplete syndrome is common. There may be accompanying carditis. The take home message for clinicians is to realize this association with COVID-19 likely exists and to have a low threshold for referral for a higher level of care.
Jones VG, Mills M, Suarez D, et al. COVID-19 and Kawasaki disease: novel virus and novel case. Hosp Pediatr. 2020; doi: 10.1542/hpeds.2020-0123
2) Self-Proning in the ED Improves Patients’ Oxygenation
A small, observational study of 50 patients with a median initial oxygen saturation of 80% found that adding oxygen by nasal canula or non-rebreather mask increased oxygen saturations to a median of 84%. Oxygen with self-proning increased oxygen saturations to a median of 94%. Ultimately, 24% went on to get intubated within the first 24 hours and 36% overall required intubation.
Comment: Awake proning is being used in the acute care wards and now in the ED to improve oxygenation. This observation study shows improvements in oxygenation, though long-term outcomes are unclear. Whether this technique reduces intubations is unknown; it is also unknown how much it reduces intubations in the ED.
These practices further support the more tranditional practices of paralysis and proning of patients with moderate/severe ARDS in the ICU with COVID.
Caputo ND, et al. Early Self‐Proning in Awake, Non‐intubated Patients in the Emergency Department: A Single ED’s Experience during the COVID‐19 Pandemic Academic Emergency Medicine 22 April 2020 https://doi.org/10.1111/acem.13994
3) Yet more good news about ACEI and ARBs in COVID-19 (but not so good about smoking, CAD, COPD)
An observational database study done at 169 hospitals in Europe, Asia and North American of 8910 patients with COVID-19 found that ACEI Sand ARBS did not worsen mortality and that ACEI seem to be protective (death in those on ACE inhibitors versus placebo (2.1% vs. 6.1%; odds ratio, 0.33; 95% CI, 0.20 to 0.54)). ARBs seemed to be neutral in terms of death. ARBs (6.8% vs. 5.7%; odds ratio, 1.23; 95% CI, 0.87 to 1.74).
CAD, age of 65 years of age, heart failure, a history of cardiac arrhythmias, COPD and current smoking all were associated with an increase in mortality.
Comment: This is the largest study to date and confirms prior data: ACEI and ARBs are at worst neutral and, in the case of ACEI may be protective in those with COVID-19. Underlying illness including COPD and current smoking are risk factors for death from COVID-19. This is not a randomized, controlled trial but is the largest data set we have to date.
Mehra MR et al. Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19 May 1, 2020 DOI: 10.1056/NEJMoa2007621
4) New Guidelines on Breast Feeding
The CDC has issued new guidelines which can be found here: https://www.cdc.gov/coronavirus/2019-ncov/hcp/care-for-breastfeeding-women.html
- Breast feeding is generally the best nutrition for an infant and COVID-19 does not SEEM to be a source of transmission of COVID-19 (though it can’t be entirely excluded yet).
- Whether to breast feed or not should be a shared decision between the mother/parents and provider.
- Hand washing and wearing a cloth facemask are critical. Note that the guideline makes no mention of N95 or surgical masks.
- Assume that the infant of a COVID-19 positive mother who is breast feeding is itself COVID-19 positive for purposes of isolation.
- Newborn and young child wellness visits (through 24 months) and vaccination should be prioritized.
- Telemedicine can provide lactation support for mothers breast feeding.
Comment: These are simplified but essentially the same as the prior breast-feeding guidelines for COVID-19 positive mothers.
5) Some good news: Remdesivir is given emergency approval by the FDA for use in COVID-19
An unpublishedstudy showed a benefit of Remdesivir in COVID-19 positive patients requiring oxygen or intubation an showed that the average time to recovery (discharge or no need for supplemental oxygen) was 11 days with Remdesivir than with placebo (15 days). There was a trend towards a mortality benefit but it did not meet statistical significance. Five day of drug seemed to be as effective as 10 days of drug.
Comment: This study continues since the requisite number of patients have not yet been recruited to assess all endpoints. We are still awaiting peer review.
6) New COVID-19 symptoms recognized by the CDC.
These can be found here https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html and include: Repeated shaking chills, muscle pain, headaches sore throat and loss of taste. The “classic” symptoms include fever, dyspnea, and cough.
There are reports of “frostbite-like” erythema and peeling of toes, especially in young patients though it is as of yet not categorized in terms of frequency. There are several possible mechanisms include microthrombi from hypercoagulability and vasospasm. There are no reviewed/published articles in the scientific literature as of yet.
A dermatology registry about COVID-19 skin manifestations is being compiled and can be found here: https://www.jaad.org/article/S0190-9622(20)30658-7/pdf
Finally, stroke and encephalopathy are being noted with increased frequency. Stroke seems more likely in the young while encephalopathy are being noted in those who are older.
Rev Neurol. 2020 May 1;70(9):311-322. doi: 10.33588/rn.7009.2020179.
Week of April 19th through April 25th
Further data on COVID-19 and pregnancy does not show excess maternal mortality or adverse fetal outcomes.
- A study from China of 118 pregnant patients who were either COVID-19 PCR positive (71%) or who had CT findings + symptoms of COVID-19 (29%) found that 92% had mild disease (the overall population rate of mild disease is approximately 81%). The other 8% had severe disease (defined in this study as hypoxia). Of the nine patients with severe disease, development was post-partum among six patients and only one patient needed non-invasive ventilation; there were no deaths. The baseline data of neonatal outcomes is not yet available, but the study authors do not raise any concerns about adverse neonatal outcomes (three spontaneous abortions, two ectopic pregnancies). 21% of deliveries (half of which were induced) were premature, but there was no neonatal asphyxia.
- Editor Comment: This is reassuring, and consistent with previous data showing that COVID-19 does not present more virulently in pregnancy. More data will likely be forthcoming.
Chen L. et al. Clinical Characteristics of Pregnant Women with COVID-19 in Wuhan, China. NEJM: April 17, 2020 DOI: 10.1056/NEJMc2009226 available here.
ACEI/ARBs do not seem to increase mortality, and may have some protective effects in patients with COVID-19
- The first study is an observational case series of 1178 hypertensive patients from China with COVID-19, 32% of which were taking an ACE or an ARB. The mortality rate in the patients with hypertension was 21% (for reference, these are select patients with hypertension and co-morbid illness) There was no mortality difference between hypertensive patients taking ARBs/ACEs and those not.
- A second and statistically superior study confirms the findings of this first study. This is a retrospective, multi-center study of 1128 adult patients with hypertension. Of these, 188 were taking an ACE/ARB. Overall mortality was lower in those on an ACEI/ARB (3.7% in those on an ACEI/ARB and 9.8% in those not on an ACEI/ARB). An analysis based on propensity score (designed to remove variables such as age, gender and comorbidities) confirmed that morality results still favored the ACEI/ARB group (adjusted HR, 0.37; 95% CI, 0.15-0.89; P = 0.03).
- Editor Comment: These results are reassuring, with one study suggesting that ACEI/ARB are at worst neutral in terms of mortality, and the other suggesting a statistically significant mortality benefit with both ACEI/ARB. More data will likely be forthcoming.
Li, J et al. Association of Renin-Angiotensin System Inhibitors With Severity or Risk of Death in Patients With Hypertension Hospitalized for Coronavirus Disease 2019 (COVID-19) Infection in Wuhan, China JAMA Cardiol. Published online April 23, 2020. doi:10.1001/jamacardio.2020.1624
Zhang, P. et al. Association of Inpatient Use of Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers with Mortality Among Patients With Hypertension Hospitalized With COVID-19 Originally published17 Apr 2020 https://doi.org/10.1161/CIRCRE... Circulation Research
Some COVID-19 patients are hypercoagulable, and may present with stroke even in the absence of other severe manifestations of COVID-19. The risk is not well quantitated.
- A case series from Italy of patients admitted to an ICU with COVID-19 found increased levels of fibrinogen and an enhanced clot formation using thromboelastometry, including a shorter clot formation time. In keeping with normal enhanced clot formation, the d-dimer was also elevated. There have also been increasing reports of stroke in relatively young people, despite the absence of other severe manifestations of COVID-19, though there is not yet well-quantified data for this
- For admitted patients, The American Society of Hematology recommends prophylaxis with enoxaparin 40mg QD as standard with intermittent pneumatic compression stockings as an alternative. See the guidelines here.
Spiezia, L. et al. COVID-19-Related Severe Hypercoagulability in Patients Admitted to Intensive Care Unit for Acute Respiratory Failure. Thrombosis and Hemostasis 21 April 2020 DOI https://doi.org/10.1055/s-0040...
Week of April 12th through April 18th
1) Some pregnant women are COVID-19 positive and asymptomatic.
A letter in the New England Journal reports that of 211 asymptomatic pregnant women being delivered in New York, 1 in 8 (13.7%) were COVID-19 positive and of these 90% were asymptomatic.
This is not unexpected given the degree of disease in New York and the fact that we know a significant portion of patients with COVID-19 are asymptomatic.
The testing of women who go into labor should be individualized to each community and should follow the local testing practice pattern.
This is consistent with expert opinion that recommend COVID-19 testing for women scheduled for induction or Cesarean section 24-28 hours before admission and again on presentation. If screening is positive, the induction or operative delivery should be delayed if medically possible. All patients (obstetrical or not, in labor or not) should be screened for symptoms. A summary of these recommendations can be found here.
Desmond S, Fuchs K, D’Alton. M. Universal Screening for SARS-CoV-2 in Women Admitted for Delivery (letter). April 13, 2020 DOI: 10.1056/NEJMc2009316
2) Data regarding surgical masks is mixed but mostly positive.
A study of 246 patients with various viruses and not just COVID-19, showed a significant reduction of virus in the aerosol and droplets of those wearing masks. For the patients tested who had non-COVID19 coronavirus there was a significant decrease in virus particles in those wearing surgical masks (in respiratory droplets, from 30% to 0%; aerosols, 40% to 0%). The same is true for influenza infection (respiratory droplets, 26% to 4%; aerosols, 35% to 22%). Masks did not seem to reduce the number of virus particles for rhinovirus.
In a 2nd study of only 4 patients with collection medium only 20cm from an individual’s face the number of virus particles cultured was similar between those using and not using masks. However, this is only 4 patients and it does not tell us about virus spread outside of 20cm (e.g. is the velocity and distance of virus dispersement different than without a mask?).
Leung NHL et al. Respiratory virus shedding in exhaled breath and efficacy of face masks. Nat Med 2020 Apr 2; [e-pub]. (https://doi.org/10.1038/s41591-020-0843-2)
Bae S et al. Effectiveness of surgical and cotton masks in blocking SARS–CoV-2: A controlled comparison in 4 patients. Ann Intern Med 2020 Apr 6; [e-pub]. (https://doi.org/10.7326/M20-1342)
3) A randomized, double-blinded trial of chloroquine for COVID-19 was stopped early in Brazil because of the development of a prolonged QT and a trend toward a higher mortality with chloroquine 600mg BID.
Eighty-one of a planned 400 hospitalized patients were enrolled using either 600mg BID of chloroquine for 10 days or 450mg BID for 5 days. All patients also got azithromycin and ceftriaxone. The high-dose arm was stopped early because of significant prolongation of the QT in 25% with a trend towards increased mortality (17% in the high dose group vs. 13% with the lower dose). It is recommended to continue to follow the IDSA guidelines for treatment which can be found here.
Silva Borba MG, de Almeida F, Sousa Sampaio V. et al. Chloroquine diphosphate in two different dosages as adjunctive therapy of hospitalized patients with severe respiratory syndrome in the context of coronavirus (SARS-CoV-2) infection: Preliminary safety results of a randomized, double-blinded, phase IIb clinical trial (CloroCovid-19 Study) doi: https://doi.org/10.1101/2020.0...
4) 30% ethanol is enough to inactivate the COVID-19 virus after 30 seconds of contact (Note: that this is not standard of care but might be applicable in low resource areas).
Questions about disinfected surfaces in the time of COVID-19 are legion. A study published by the CDC in the “Emerging Infectious Diseases” on 14 April 2020 suggests that 30% ethanol is just as effective as 80% ethanol. They did quantitative inactivation studies of COVID-19 viruses and looked at various dilutions of ethanol and 2-propranol. The caveat is the contact has to be for at least 30 seconds. All of the WHO-recommended solutions work, as well.
Discussion: This is not recommended this as a routine practice. If resources are very limited, this offers another option.
Kratzel A, Todt D, V’kovski P, Steiner S, Gultrom M, Thao TTN, et al. Inactivation of severe acute respiratory syndrome coronavirus 2 by WHO-recommended hand rub formulations and alcohols. Emerg Infect Dis. 2020 Jul [date cited]. https://doi.org/10.3201/eid2607.200915