COVID-19


GW COVID-19 Intelligence Report

Obtained from GW Himmelfarb Library | Report generated on August 24, 2020
Created by GW School of Medicine and Health Sciences, Himmelfarb Health Sciences Library and the GW Covid-19 Incident Management Intelligence Unit

Policy and New

  • Crisis Standards of Care (CSC) provide a framework for the fair allocation of scarce resources during emergencies, however, there is wide variability in the existence and specificity of CSC across the US and the authors conclude, "CSC may disproportionately impact disadvantaged populations due to inequities in comorbid condition prevalence, expected lifespan, and other effects of systemic racism."

Epidemiology

  • In this large cohort of children (from our own Children's National Hospital) tested for SARS-CoV-2 through a community-based testing site, racial/ethnic minorities and socioeconomically disadvantaged children carry the highest burden of infection.
  • A prospective, observational cohort study of the general community (over 2 million individuals in the UK and US), including nearly 100,000 front-line health-care workers, using self-reported data, showed risk was increased among front-line health-care workers.
  • A study of an outbreak of SARS-CoV-2 on a fishing vessel showed that presence of neutralizing antibodies from prior infection was significantly associated with protection against re-infection.

Disease Presentation, Course, and Complications

Pediatrics:

  • The common clinical pediatric COVID-19 presentations and diagnostic testing are reviewed including laboratory and radiological features and described treatment and complications. Fever, cough and lymphopenia, which are common in adult presentation, are not consistently so in pediatric disease.
  • CDC has updated their Advisory on multisystem inflammatory syndrome in children (MIS-C) which is a rare but severe condition that has been reported approximately 2–4 weeks after the onset of COVID-19 in children and adolescents and advises that clinicians must readily distinguish this from other severe inflammatory conditions in children.
  • Analysis of pediatric COVID-19 hospitalization data from 14 states found one in three hospitalized children was admitted to an intensive care unit. Children are at risk for severe COVID-19.

Internal Medicine:

  • In a cohort study of patients who had recently recovered from COVID-19, cardiac magnetic resonance imaging revealed cardiac involvement in 78 patients (78%) and ongoing myocardial inflammation in 60 patients (60%) highlighting the potential for long-term cardiac consequences of COVID-19 infection.
  • Preliminary evidence from a systematic review and meta analysis of 11 cohort students including nearly 2,000 patients indicates that prophylactic-dose thromboprophylaxis may be inadequate to control the increased risk of venous thromboembolism (VTE) in patients hospitalized for coronavirus disease 2019 (COVID-19) infection.
  • Systematic review of 41 studies and over 5,000 patients provides clinical and radiologic guidance for early identification of severe COVID-19 patients in order to identify those to transport to specialised centres and initiation of appropriate treatment.
  • A systematic review (62 studies and over 8,000 patients) and meta analysis (26 studies and 4700 patients) show that GI and hepatic involvement should be investigated in patients with COVID-19 since it portends a severe clinical course.

Geriatrics:

  • Four cases of elderly patients developed altered mental status as their primary COVID-19 presenting symptom without associated fever or respiratory symptoms.

Dermatology:

  • Dermatological lesions are frequent in patients with SARS-CoV-2, especially erythema, urticaria, and varicella-like rash. The rash is not correlated to the severity of SARS-CoV-2 infection.

Neurology:

  • Considering neurological involvement in patients with SARS-CoV-2 infection can result in earlier diagnosis and treatment. Particularly, young adults with unexplained and unexpected stroke as well as patients with newly diagnosed Guillain–Barré syndrome should be tested for SARS-CoV-2 infection
  • Patients with COVID-19 presenting with acute neurologic symptoms warrant a lower threshold for suspicion of large vessel stroke, and prompt workup for large vessel stroke is recommended.

Transmission

  • Study of the Diamond Princess Cruise Ship shows close-range and long-range transmission likely contributed similarly to disease progression aboard the ship, with fomite transmission playing a smaller role.
  • This quality improvement study of samples from an ophthalmology examination room showed viral material was found on room surfaces, however, the infectivity of the virus samples was unknown.
  • Viral load was similar between asymptomatic and symptomatic patients; therefore, isolation of infected persons should be performed regardless of symptoms.
  • Patients with respiratory manifestations of COVID-19 produce aerosols that contain viable SARS-CoV-2 in the absence of aerosol-generating procedures, and these aerosols may serve as a source of transmission of the virus.
  • Vertical transmission of SARS-CoV-2 is possible and appears to occur in a minority of cases of maternal COVID-19 infection in the third trimester
  • Assessment of SARS-CoV-2 on an international flight does not rule out the possibility of airborne transmission in an airplane cabin.

Risk Factors

  • A prospective population-based cohort study shows that existing use of ACE inhibitors and ARBs are associated with reduced risks of COVID-19 disease after adjusting for a wide range of variables. And another large single center retrospective analysis observed a protective effect of pre-hospitalization use of RAS inhibitors on mortality in hypertensive COVID-19 patients.
  • The Veterans Health Administration analyzed EHR of nearly 7,000 Veterans diagnosed with SARS-CoV-2 infection and developed a COVID-19 Care Assessment Need (CAN) score, which is an efficient way to utilize existing EHR data to predict the clinical course.
  • A retrospective study identified seven easily available prognostic factors and proposed a simple nomogram for early detection of patients at risk of disease aggravation, in order to optimize clinical care and initiate specific therapies. Those factors are age, respiratory rate, overweight, temperature, C-reactive protein, troponin and lymphocyte counts were risk factors of an unfavorable outcome in hospitalized adult patients.
  • The BMI plays a significant role in COVID-19 infection and severity at all ages, especially in the elderly population.
  • A retrospective observational study found that history of macular degeneration (a proxy for complement-activation disorders) and history of coagulation disorders (thrombocytopenia, thrombosis and hemorrhage) are risk factors for SARS-CoV-2-associated morbidity and mortality.

Treatments & Research

  • Variegated T cell memory to coronaviruses that cause the common cold may underlie at least some of the extensive heterogeneity observed in COVID-19 disease.
  • Rhesus macaque models of SARS-CoV-2 infection found that animals developed immune responses that protected against a second infection.
  • In a large cohort of hospitalized patients admitted with COVID-19, bacterial, fungal and viral co-infections and super-infections were low; however, when present, they may cause severe diseases with worse outcomes.
  • Based on an analysis of 23 RCTs, glucocorticoids were the only intervention with evidence for a reduction in death compared with standard care.
  • A clinical practice guideline recommends remdesivir for patients with severe COVID-19.
  • Good outcomes for patients with critical COVID-19 can be achieved with early noninvasive–invasive sequential ventilation and bundled pharmacotherapy.
  • A review of seven studies, including two RCTs and five cohort studies, with a total of 5444 patients concludes that convalescent plasma therapy may be an effective therapeutic option, until the availability of therapeutic and/or prophylactic agents for COVID-19, with some early, promising evidence on safety, viral clearance, and reduction in mortality. NOTE: On August 23, the US FDA granted an Emergency Use Authorization for the use of this therapy.
  • Many trials of potential therapies for COVID-19 disease are underway. Current evidence does not support a clear role for any specific pharmacotherapy in COVID-19 yet.
  • There is insufficient evidence regarding the clinical efficacy and safety of tocilizumab in patients with COVID-19.
  • Novaferon exhibited anti-SARS-CoV-2 effects in vitro and in COVID-19 patients.
  • Given the potential differences in response to anticoagulant therapy, it remains unclear whether standard dosing effectively achieves the appropriate level of anticoagulation among hospitalized COVID-19-positive African Americans.
  • A study found evidence of an association between receipt of the bradykinin 2 receptor antagonist icatibant and improved oxygenation.
  • Use of ACEI/ARB does not worsen the prognosis of COVID-19, and could even be protective in hypertensive subjects. RAAS inhibitors should be continued in patients who are at risk for, are being evaluated for, or have COVID-19.
  • No significant differences among three regimens of several antiviral regimens in effectiveness in patients with mild to moderate COVID-19 were found in this study.

Vaccines

  • The inactivated COVID-19 vaccine had a low rate of adverse reactions and demonstrated immunogenicity, but longer-term assessment of safety and efficacy will require phase 3 trials.

Diagnostic Testing

  • The U.S. Food and Drug Administration authorized the first two COVID-19 serology tests that provide an estimated quantity of antibodies present in the individual’s blood.
  • Preliminary findings indicate that trained detection dogs can identify respiratory secretion samples from hospitalized and clinically diseased SARS-CoV-2 infected individuals.

PPE

  • Facial masks work to prevent the spread of viral particles from asymptomatic individuals to others and by reducing the inoculum of virus to which a mask-wearer is exposed which will result in milder disease.
  • Mandatory mask-wearing policies reduced face-touching behavior among the general population in public areas.
  • Nine minutes of UVC irradiation represents a suitable disinfection method for SARS-CoV-2.

Resources

  • Comprehensive COVID Care Resources from the Cleveland Clinic are available in English and Spanish.