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CMAAO Coronavirus Facts and Myth Buster 83

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Dr KK Aggarwal    05 May 2020

With additional inputs from Dr Monica Vasudeva

778: Universal Face Shields for COVID-19

The CDC has recommended that all Americans should wear cloth masks in public to check the transmission of COVID-19 coronavirus, but another form of personal protective equipment - plastic face shields - might be a better idea.

A JAMA Viewpoint recently published by Eli Perencevich, MD, of the University of Iowa, and colleagues discussed how face shields for the community may be a viable alternative.

Face shields can be reused indefinitely and can be easily cleaned with soap and water, or common household disinfectants. They are comfortable to wear, protect the portals of viral entry, and even diminish the potential for autoinoculation by preventing the wearer from touching their face.

Additionally, face shields do not have to be removed to communicate with others.

A simulation study of influenza virus noted that face shields reduced viral exposure by 96% when worn within 18 inches of a cough, and when this study was repeated using the recommended distancing protocol of 6 feet, inhaled virus was reduced by 92%. Face shields form an important PPE component for healthcare workers.

779: COVID-19 Might Be Most Transmissible in the Presymptomatic Period

Anthony L. Komaroff, MD reviewed He X et al. Nat Med 2020 Apr 15

Peak infectivity is estimated to occur 2 days prior to symptom onset.

Influenza has been shown to be most transmissible at or just before the onset of symptoms, while SARS is most transmissible at 7 to 10 days after symptom onset.

A team from Wuhan, China, created models based on data from two different studies of patients with COVID-19. Overall, 414 serial throat swabs were obtained from 94 moderately ill patients, starting at symptom onset and continuing for the next 32 days. This was followed by obtaining data from 77 transmission pairs and estimation of an incubation period of 5.2 days. The researchers found the highest viral loads on throat swabs collected at symptom onset. The loads were found to rapidly decline over the next 7 days. They estimated that 44% of secondary cases were infected in the 2 days prior to onset of symptoms, at least among transmissions that occurred among people in close contact (e.g., households).

The researchers concluded that COVID-19 is highly infectious in the 2 days before symptom onset. The conclusion is based on modeling: No samples were obtained in patients before onset of symptoms. The findings are; however, consistent with anecdotal evidence of relatively frequent spread by asymptomatic carriers. If this hypothesis is correct, quarantining will be less effective in controlling this virus than it was with SARS, and aggressive tracing of contacts will be the key. [NEJM]

780: SARS-CoV-2 Found in Aerosols in Hospital Staff Areas, Public Places;

New findings, published in the journal Nature, provide additional evidence indicating that SARS-CoV-2 can persist in aerosol samples. Researchers in Wuhan quantified SARS-CoV-2 RNA concentrations in aerosol samples obtained from 30 sites inside two hospitals dedicated to treating COVID-19, as well as from several public areas.

In patient areas, viral RNA concentrations were very low or undetectable (e.g., ICUs, coronary care unit), except in a patient mobile toilet room, which was not ventilated.

In medical staff areas, some sites, including rooms where PPE was removed, had high SARS-CoV-2 RNA levels. However, the levels became undetectable following better sanitization procedures.

Among public areas, two areas that got a lot of foot traffic, i.e., the entrance to a department store and a site next to one of the hospitals, had high viral RNA concentrations.

SARS-CoV-2 may be potentially transmitted via aerosols. Room ventilation, open space, sanitization of protective apparel, and appropriate use and disinfection of toilet areas can help limit the concentration of SARS-CoV-2 RNA in aerosols. [NEJM]

781: COVID-19 in Healthcare Personnel

Stephen G. Baum, MD reviewed Heinzerling A et al. MMWR Morb Mortal Wkly Rep 2020 Apr 17 Burrer SL et al. MMWR Morb Mortal Wkly Rep 2020 Apr 17 Chow EJ et al. JAMA 2020 Apr 17

Initial data on vulnerability to, manifestations of, and steps to prevent COVID-19 in healthcare workers have been presented in three early studies.

SARS-CoV-2 infection of healthcare personnel (HCP) was imminent, provided the virus is highly contagious via the respiratory route and has the potential to be transmitted from symptomatic, presymptomatic, and asymptomatic persons and given the shortage of appropriate personal protective equipment (PPE).

Three groups have reported details of early HCP infections with SARS-CoV-2.

Heinzerling and colleagues reported HCP exposure from one of the earliest community-acquired cases in Solano County, California, in February 2020. An unsuspected, and hence undiagnosed patient was subjected to multiple aerosol-generating procedures under only standard precautions that exposed some 121 HCP. Of these, 35.5% developed COVID-19–compatible symptoms within 14 days of exposure and were tested for SARS-CoV-2.

Three among these had positive tests; these and 34 other HCP were interviewed. It was noted that risk factors for COVID-19 acquisition included doing a physical examination and having long exposure during nebulizer treatments.

Those with high or medium risk were monitored. Of 145 HCP with potential exposure being monitored, 36% became symptomatic and were tested for SARS-CoV-2, still yielding only the 3 positive HCP, one considered at medium exposure risk and 2 at high risk. None of these 3 HCP consistently wore significant PPE. Since little community infection was present, and given the lack of HCP PPE, these infections are considered to be work-associated.

Burrer and colleagues characterized 9282 HCP-associated cases of COVID-19 in the U.S. up to April 9, 2020. Median age was 42 years and 73% were female. Where racial data were available, 72% were white, 21% were Black, and 5% were Asian. Exposure was noted in healthcare (55%), households, and community settings, with 38% reporting at least one underlying health condition. Most reported fever, cough, or shortness of breath; 8% reported no symptoms. About 90% were not hospitalized, but severe outcomes including 27 deaths occurred, mostly in HCP aged ≥65 years.

Chow and colleagues assessed the efficacy of current COVID-19 screening practices in HCP. Among 50 HCP identified as exposed and infected in King County, Washington, in February 2020, 48 were interviewed. Median age was 43 years, 77.1% were female, and 77.1% were involved in direct patient care. About 47.9% reported chronic medical conditions. The most common symptoms included cough (50%), fever (41.7%), and myalgias (35.4%). Of the 16.7% without cough, fever, shortness of breath, or sore throat, the most common complaints included chills, myalgias, coryza, and malaise.

The authors stated that if chills and myalgias had been included in screening, case detection would have gone up from 83.3% to 89.6%. Among those who were interviewed, 64.6% reported working a median of 2 days (range, 1–10 days) while symptomatic. [NEJM Reproduced]

782:  A pregnant woman in Switzerland delivered a stillborn infant at 19 weeks gestation after testing positive for COVID-19

David Baud, MD, PhD, of the Lausanne University Hospital in Switzerland, and colleagues, reported in JAMA that this case of miscarriage during the second trimester of pregnancy in a woman with COVID-19 seems to be related to placental infection with SARS-CoV-2, supported by virological findings in the placenta.

After delivery, swabs and biopsies of the placenta tested negative for bacterial infection, but positive for SARS-CoV-2. The placenta remained positive at 24 hours after delivery.

Placental infection leading to miscarriage or fetal growth abnormalities were noted in 40% of maternal infections with SARS and MERS coronaviruses. [Medpage Today]

783: The novel coronavirus (SARS-CoV-2) stays significantly longer in stool than in the lungs and serum

Reuters: The management of stool samples is important for controlling the virus, suggest clinicians in China.

Dr. Tingbo Liang and colleagues of First Affiliated Hospital in Hangzhou estimated the viral load from 3497 respiratory, stool, serum and urine samples from 96 patients with SARS-CoV-2 infection.

Infection was confirmed in all patients by means of sputum and saliva samples, report researchers in The BMJ. RNA was detected in the stool of 55 (59%) patients, in the serum of 39 (41%) patients, and the urine of only one patient.

The average lifespan of the virus was estimated as 22 days (range 17-31 days) in stool compared to 18 days (range 13-29 days) in respiratory tissue and 16 days (range 11-21 days) in serum.

The virus was found to persist for a longer period and peak later in respiratory tissue in people with severe disease. The average duration of virus in respiratory samples of patients with severe disease was 21 days (range 14-30 days) compared with 14 days (range 10-21 days) in those with mild disease.

Among patients with mild disease, the viral loads peaked in respiratory samples in the second week following disease onset, whereas viral load continued to be high during the third week in those with severe disease.

Reducing viral loads through clinical means and strengthening management during each stage of severe disease can go a long way in preventing the spread of the virus.

The virus was also found to persist longer in men than women and in patients over age 60 years, which may explain, in part, the high rate of severe illness in older patients.

784: Case Definition Published for Rare Child Syndrome

Pediatricians from UK have published a working definition of an inflammatory syndrome affecting a very small number of children that may be linked to COVID-19.

The working definition includes:

  • A child presenting with persistent fever, inflammation and evidence of single or multi-organ dysfunction with additional features. This may include children fulfilling full or partial criteria for Kawasaki disease.
  • Exclusion of any other microbial cause.
  • SARS-CoV-2 PCR testing may be positive or negative.

[Medscape]

785:  Nearly two-thirds of U.S. patients with COVID-19 report gastrointestinal symptoms, according to a multicenter study.

Harvard Medical School: Overall, 61.3% of patients presented with at least one gastrointestinal symptom, including most commonly anorexia (34.8%), diarrhea (33.7%), and nausea (26.4%).

Gastrointestinal symptoms were the initial symptoms in 14.2% of patients and constituted the predominant presenting complaint in 20.3% of patients, suggested the online report in Gastroenterology.

More patients with, than without, gastrointestinal symptoms also had fatigue (65.1% versus 45.5%, respectively), myalgia (49.2% versus 22%), sore throat (21.5% versus 9.8%), and loss of smell or taste (16.9% versus 6.5%).

Nausea and anorexia were found to have significant association with anosmia and ageusia after controlling for other factors, while other gastrointestinal symptoms were not.

Laboratory findings did not differ significantly between patients with and without gastrointestinal symptoms.

Of the 202 patients who had completed their hospitalizations at the time of data analysis, 17.5% needed ICU stay, 13% required mechanical ventilation, and 15.8% died. These rates did not differ significantly between patients with and without gastrointestinal symptoms.

It is important to consider COVID-19 in patients presenting with new or acute-onset digestive symptoms, even in the absence of respiratory complaints, fevers, or other typical COVID-19 symptoms.

Failure to identify COVID-19 patients with primarily digestive symptoms might result in delayed care, inadequate isolation, and further transmission.

Patients presenting with new or acute-onset digestive symptoms should be triaged and treated in the same way as patients presenting with respiratory COVID-19 symptoms.

786: Fact: There were trends toward lower rates of ICU stay and death in the group with gastrointestinal symptoms, which is similar to early trends seen in New York City.

 

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

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