COVID-19


GW COVID-19 Intelligence Report

Obtained from GW Himmelfarb Library | Report generated on July 27, 2020
Created by GW School of Medicine and Health Sciences, Himmelfarb Health Sciences Library and the GW Covid-19 Incident Management Intelligence Unit

Epidemiology

National and local trends demonstrate increasing new infections:

  • As of July 23rd, 144,000 people had died of COVID-19 in the U.S., and total cases reached 4 million, increasing from 3 million in only 15 days. Total number of cases doubled in 6 weeks. New hot spots — where daily cases are increasing over the past 14 days and testing positivity rate is increasing or is greater than or equal to 10% — include CA, TX, FL, AZ, and LA.
  • The CDC director estimated that there may be 10 other infections for every reported case and that 5-8% of Americans may have contracted the virus.
  • The DMV had increased cases in July, particularly in younger patients. Recent data show 66% of cases and 29% of hospitalizations in patients <40yo, compared with 41% and 16% before July.

Transmission

Airborne transmission is likely, children spread virus more than adults and asymptomatic case rate is significant:

  • Aerosol samples collected around COVID-19 patients at the University of Nebraska demonstrated the presence of infectious, replicating virions, indicating airborne transmission is possible.
  • A South Korean study indicated that children between 10-19yo can spread the virus as much or more than adults. For index patients 10-19yo, 18.6% of household contacts had COVID-19 compared with 11.8% for all index patients.
  • An Italian study found 42.5% of confirmed SARS-CoV-2 detections were asymptomatic. There was no significant difference in the viral load of symptomatic verses asymptomatic infections.

Disease Presentation, Course, and Complications

Co-Infection:

  • Community acquired coinfection was identified in 3.7% of hospitalized COVID-19 patients and in 41% of patients admitted to ICU. Antibiotics were used in 69% of patients overall.

Dermatology:

  • Chillblains, or “COVID toes”, were reported to result from sedentary lifestyles and lack of warm footwear. Analysis of a variety of cutaneous manifestations of COVID-19 demonstrated that morbilliform was the most common; pernio-like lesions were common in patients with mild disease; and retiform purpura presented exclusively in ill, hospitalized patients. Certain skin changes may be the only signs of COVID-19 infection.

Hematology & Immunology:

  • A multi-institution study found no relationship between blood type and COVID-19 severity, though types B and AB and Rh+ status were associated with a greater chance of testing positive (AOR 1.28, 1.37, and 1.23, respectively).
  • Antibody response to COVID-19 showed 95% of cases had seroconversion and neutralizing antibody response. Declining neutralizing antibodies were detected in samples up to 90 days after symptoms onset. Long-lasting CD4 and CD8 T cells developed and recognized multiple regions of the SARS-CoV-2 nucleocapsid protein.
  • Three immunotypes in COVID-19 patients were shown to be associated with poor clinical outcomes.

Laboratory Studies:

  • A study from Wuhan showed that, for patients presenting with moderate COVID-19, higher levels of neutrophil: lymphocyte count and CRP on admission were associated with poor prognosis.

Neurology:

  • Neurological complications of COVID-19 include encephalopathies, inflammatory CNS syndromes; ischemic stroke; peripheral neurologic disorders; and miscellaneous central disorders.

Obstetrics & Pediatrics:

  • Mothers infected with SARS-CoV-2 had no transmission to newborns while breastfeeding and sharing rooms, indicating transmission is unlikely when proper hygiene precautions are taken.
  • Pregnant women with COVID-19 were significantly more likely than nonpregnant women to require hospitalization, intensive care, and mechanical ventilation, but were not at greater risk of death. Black women were disproportionately affected by SARS-CoV-2 during pregnancy.
  • Use of lung ultrasound was found to be more predictive in detecting COVID-19 infection in pregnant women admitted to the hospital than screening based on symptomatology alone.
  • In Multisystem Inflammatory Syndrome in Children (MIS-C), median age was 8.3 years, 73% were previously healthy, 62% were male, 70% had positive PCR or antibody testing, 80% required ICU, and 2% died. The CDC reported 342 cases and 6 deaths due to MIS-C, 71% in Latino or Black children.

Risk Factors

  • The CDC expanded the risk factors for severe illness from COVID-19, removing the 65yo threshold and warning that risk increases steadily with age. CKD, COPD, Obesity (BMI greater than or equal to 30), immunocompromise, serious heart conditions, sickle cell disease, and Type 2 diabetes increase the risk of severe illness.
  • Hospitalized COVID-19 patients with HIV were not found to have differences in adverse outcomes compared to similar non-HIV patient groups.
  • Non-White hospitalized COVID-19 patients were more likely to present with increased disease severity on admission chest radiographs than White/Non-Hispanic patients.
  • Use of ACE-Is and ARBs did not increase the risk of severe or lethal COVID-19; ARB use may be associated with lower mortality. Severe COVID-19 patients on chronic ACEIs/ARBs have an increased risk of AKI predicted by increased urea nitrogen.
  • Statin use was associated with lower risk of mortality in COVID-19 patients in a retrospective study.
  • Risk factors for pulmonary embolism in COVID-19 patients did not include traditional thrombo-embolic risk factors; clinical and biological findings at admission, including CRP, were associated with PE.
  • A system to predict survival in hospitalized COVID-19 patients showed older age, LDH, elevated neutrophil: lymphocyte ratio, and high direct bilirubin were predictive of 28-day mortality.
  • Biomarkers including IL-6, CRP, ferritin, LDH, and D-Dimer, can aid in detection of hospitalized COVID-19 patients at risk of deterioration. LDH and D-dimer were most associated with mortality and CRP and DDimer were most associated with ICU transfer and intubation.
  • The sepsis-induced coagulopathy scoring system can be used for early assessment and management of COVID-19 patients with critical disease; low platelets, and increased PTT, D-Dimer, and neutrophil: lymphocyte ratio are predictive of increased disease severity.
  • An increased incidence of stress cardiomyopathy was found during the pandemic (7.8% vs. <2% prepandemic), suggesting a contribution of psychological, social and economic stressors.

Key Diagnostic Testing Updates

  • Antibody tests 1 week after first symptoms detected only 30% of people who had COVID-19; accuracy increased in week 2 (70%), and was highest in week 3 (> 90%). In 2% of those without COVID-19, antibody tests gave false positive results. A CRISPR-based assay was developed to improve diagnosis of COVID-19.

Key Treatments & Research Updates

  • RECOVERY trial data showed that dexamethasone reduced 28-day mortality in hospitalized COVID-19 patients receiving respiratory support.
  • Treatment with colchicine was associated with reduced clinical deterioration but no difference in troponin levels in a RCT of 105 hospitalized COVID-19 patients.
  • Remdesivir showed favorable safety and pharmacokinetic profiles supporting once-daily dosing. Prioritization of remdesivir was recommended for hospitalized patients requiring low-flow supplemental oxygen. Some benefit was shown for hospitalized patients on room air, but not for those requiring highflow oxygen, noninvasive or invasive mechanical ventilation. Treatment for 5 days was recommended.
  • Sarilumab use for IL-6 blockade in patients with severe COVID-19 and systemic hyperinflammation was not significantly associated with clinical improvement. Tocilizumab was associated with a 45% reduction in death in COVID-19 patients requiring mechanical ventilation and in clinical improvement in 74% within 14 days. Early response to it was associated with increased survival and shorter hospital stay. Favipiravir was shown to be of some benefit as an anti-inflammatory in severe COVID-19.
  • Hydroxychloroquine treatment had no benefit in mild COVID-19, nor did it substantially reduce symptom severity in symptomatic COVID-19 outpatients.
  • A meta-analysis and living systematic review revealed continued uncertainty over whether convalescent plasma is beneficial and safe for hospitalized COVID-19 patients.
  • The Radiological Society of North America (RSNA) established a COVID-19 Open Radiology Database to provide imaging data and supporting clinical information for education and research.

Key Vaccine Updates

  • The ChAdOx1 nCoV-19 vaccine showed an acceptable safety profile and humoral and cellular responses. An Ad5-vectored COVID-19 vaccine was determined to be safe and induced significant immune responses in the majority of recipients after one dose. An mRNA-1273 vaccine induced immune responses in all participants without trial-limiting safety concerns.
  • A National Academies committee will assist policymakers with equitable allocation of COVID-19 vaccines.

Public Policy & News

  • The DC Mayor ordered all persons leaving their residences to wear masks with limited exceptions and, has instituted a requirement that anyone coming to DC from 27 states with ‘hot spots’ must quarantine for 14 days.
  • HHS ordered hospitals to submit data on ICU capacity, ventilator use, PPE, and staffing shortages to its Teletracking system or state health departments rather than to the CDC.
  • The Republican National Convention was cancelled due to the flare-up of COVID-19 in Florida.
  • The Trump administration stated schools must reopen. Montgomery, Prince George’s, Arlington, and Fairfax Counties will begin with full-time distance learning in the Fall. DC has not announced its plans.
  • Dr. Anthony Fauci threw the first pitch at the opening Washington Nationals game on 7/23. Star player Juan Soto, 21yo, tested positive for coronavirus hours before the game.