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July 13 | Daily COVID-19 LST Report

Climate:

- Researchers at Washington University mapped current trends in COVID-19 transmission in the US using geographical mapping software and county-level data on reported infections between January 22 and May 13, 2020. They found cases had decreased in the Northeastern states (down 16.6% per week) but had consistently increased in the Midwest, South, and Western states (up 13.2%, 5.6%, and 5.7% per week, respectively). Additionally, the incidence of COVID-19 has been consistently increasing in rural counties and counties with majority-minority populations, raising concern because these communities have less healthcare resources to mitigate a surge.

- Authors highlight the vulnerabilities faced by people who use drugs (PWUD) during the COVID-19 pandemic because of their increased risk for homelessness, interactions with the criminal justice system, and need for in-person substance use treatment. To address these vulnerabilities, they recommend international stakeholders create policies and programs to invest in public health infrastructure, prioritize decriminalization, and increase access to harm reduction programs and telemedicine for substance use services.



Epidemiology:

- Public health experts from Seattle performed a retrospective analysis of 124 COVID-19 positive patients who received Emergency Medical Services, finding that 46% of patients resided in long-term care facilities, 37.9% had 3 or more chronic health comorbidities, and 52.3% died. Additionally, 43 of 147 encounters (29.3%) were negative for fever, cough, or shortness of breath. Authors conclude that this heterogeneity in symptomatology highlights the need to improve current COVID-19 screening tools, and prevent nosocomial transmission in pre-hospital settings.

- This case series documents COVID-19 disease course in 4 febrile hospitalized neonates, all of whom had favorable outcomes. Two neonates required ICU admission for respiratory insufficiency, two neonates had a co-infection (E. Coli., human metapneumovirus), and one neonate was successfully treated with remdesivir. These findings suggest that neonates presenting with fever, a common condition, should be assessed for potential COVID-19 infection during the pandemic.

Understanding the Pathology:

- A retrospective cohort study involving 127 children with COVID-19 found that "decreased levels of globulin, IgA, and CD4+CD25+ T lymphocyte percentage and increased concentration of hs-CRP, procalcitonin, and IL-10 were associated with the presentation of pneumonia in chest radiologic findings". These findings suggest that "immune-related factors may participate in the pathogenesis of pneumonia in children with COVID-19" similarly to adults.

- A literature review by Chinese researchers describe the pathophysiology of SARS-CoV-2 infection in patients with intracerebral hemorrhage (ICH). Specifically, they discusses virus entry into the brain through ACE2 receptors, subsequent disruption of two pathways in the brain involved in maintaining cerebral homeostasis, destruction of the blood brain barrier allowing infiltration of immune cells into the brain, and oxidative tissue damage due to the immune response. This review highlights the increased risk of poor outcomes in ICH patients with COVID-19 and the need for early diagnosis, isolation, and treatment.

Transmission and Prevention:

- An analysis conducted on COVID-19 mortality and bacillus Calmette−Guérin (BCG) vaccine data collected until 22 April 2020 found a global negative association between BCG vaccination policy and COVID-19 mortality. When potential confounding variables such as Human Development Index (life expectancy, education level, and per capita income), ≥15% of population over 65 years of age, and urbanization were mitigated, the overall significance was reduced, but countries with stronger BCG vaccination policies still had a lower COVID-19 mortality rate. These results suggest the BCG vaccine may confer protection from COVID-19 by enhancing the innate immune system, however, further randomized trials and data are needed.

- Researchers in the Netherlands analyzed the effectiveness of social media education campaigns. They administered an initial survey of 16,072 participants through social media with questions about handwashing, face touching, and physical distancing, followed by a multimedia campaign with virologist and social media influencer Govert Sweep and a popular national newspaper, “De Telegraaf.” A post-campaign survey 3 days later revealed that participants who saw both components of the campaign reported an improvement in personal hygiene and physical distancing during the COVID-19 crisis, suggesting a potential value for the use of similar multimedia campaigns to improve these behaviors.

Management:

- A systematic review conducted at Geneva University Hospital in Geneva, Switzerland of 11 studies (n=1,369) found that venous thromboembolism (VTE) is a more common complication of COVID-19 in inpatients than in outpatients. Additionally, guidelines continue to recommend VTE prophylaxis in all hospitalized COVID-19 patients regardless of symptoms. However authors note that the dosing of VTE prophylaxis varies between guidelines, suggesting more research needs to be done to determine the therapeutic dose.

- A review of 11 studies by Greek researchers found significant heterogeneity in the reported venous thromboembolic (VTE) phenotypes of hospitalized COVID-19 patients. Authors suggest the heterogeneity could be due to specific risk factors, including patient age, sex, VTE history, and SARS-CoV-2 specific factors (ie., coagulopathy, endothelial injury/microthrombosis). Due to this variation and unpredictability as well as evidence suggesting VTE is associated with more severe disease (see below), they recommend increased d-dimer screening for VTE and thromboprophylaxis in all hospitalized patients.

Adjusting Practice During the Pandemic:

- Experts in psychiatry and neuro-ethics argue that tele-psychiatry should continue to be utilized after the COVID-19 pandemic passes. They develop their stance through the lens of medical ethics principles and maintain the following: 1) Continuing to offer tele-psychiatry services is necessary for the sake of patient benefice and autonomy. 2) Doing so would likely yield significant cost-savings for patients and other stakeholders. 3) Increasing tele-psychiatry accessibility would yield a greater degree of distributive justice.

R&D Diagnosis and Treatment:

- Radiologists in Wuhan, China conducted retrospectively compared chest computed tomography (CT) findings between survivors (n=83) and non-survivors (n=41) of COVID-19 infection. They found that non-survivors had more bilateral (97% vs 73%) and diffuse (39% vs 8%) findings, and a predominant “crazy-paving” pattern on chest CT (appearance of ground glass opacity with superimposed interlobular septal thickening). Curve estimation showed rapidly increased total CT score (0 = no involvement to 25 = maximum involvement) in non-survivors that remained high until acute respiratory distress syndrome (ARDS) and subsequent death occurred, while total CT score increased slowly followed by a gradual decline in survivors. Authors suggest crazy-paving pattern predominance and total CT score trends may assist in identifying high risk patients prior to clinical deterioration.

- A neural network program that analyzed electronic health records from 77,167 COVID-19 patients at the Mayo Clinic to better categorize symptomatology. They found that anosmia/dysguesia was increased 27.1 fold in COVID-19 positive patients, and was the earliest sign of infection. Additionally, cough plus fever/chills (4.2 fold), myalgia/arthralgia (2 fold), and diarrhea (1.7 fold) were also seen in RT-PCR positive patients. These findings highlight the utility of artificial intelligence methods in enhancing EHR to facilitate real-time diagnostic support of COVID-19 infection.

- A literature review from the Department of Rheumatic and Immunologic Diseases at the Cleveland Clinic highlights the use of IL-1 antagonists such as anakinra and canakinumab as effective drug choices to improve outcomes of patients with cytokine release syndrome secondary to COVID-19. Modulation of IL-1 may decrease hyperactive pulmonary macrophages from releasing IL-1 and other inflammatory cytokines. Preliminary evidence indicates that anakinra and canakinumab, drugs that block the action of IL-1 and have a good safety profile and improve the outcomes of patients with COVID-19 cytokine release syndrome. Results from large, randomized clinical trials are pending.


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