COVID-19: TCTMD’s Daily Dispatch for August 7
We’re curating a list of COVID-19 research and other useful content, and updating it daily.
TCTMD reporter Todd Neale is keeping up on breaking news and peer-reviewed research related to COVID-19 and will update daily. If you have something to share, tell us. All of our COVID-19 coverage can be found on our COVID-19 Hub.
August 7, 2020
Viral load, which can be calculated from RT-PCR tests, may be an important tool for risk stratification, say researchers in New York City. Their prospective analysis of nasopharyngeal swab samples in 1,145 patients who tested positive for SARS-CoV-2 showed that viral load was significantly and independently lower for patients alive at the end of the study as compared with those who’d died. “To our knowledge, we are the first to report on SARS-CoV-2 viral load at diagnosis as an independent predictor of mortality in a large hospitalized cohort,” Elisabet Pujadas, MD, PhD, and colleagues report in the Lancet.
On June 8, 2020, authorities in New Zealand announced they’d moved to Alert Level 1, effectively implying the pandemic was “over.” How did New Zealand manage to “eliminate” COVID-19? Some answers online in the New England Journal of Medicine today.
On NEJM.org, editors interview Harvard’s Arnold Epstein, MD, about the “collateral impact” of COVID-19 on the care of other diseases and the US health system as a whole.
A retrospective study hydroxychloroquine and azithromycin use at a single hospital indicates that patients experienced a “significant and progressive increase in QTc during combination drug therapy,” with one in five experiencing increases of 500 milliseconds or more. Changes were not associated with death over the short duration of the study, where mortality was already high, researchers report in JACC: Clinical Electrophysiology. Higher age, body mass index less than 30, heart failure, elevated creatinine, and troponin elevation were all predictive of larger QTc changes.
Elisabeth Mahase, writing in the BMJ, provides a simple overview of “where we are on immunity and vaccines.”
There’s another case report of a patient presenting late for STEMI who developed ventricular septal rupture, published in JACC: Case Reports. In the American Journal of Cardiology, investigators describe a case of extensive arterial thrombosis affecting the infrarenal abdominal aorta near the aortic bifurcation, occlusion of the left common iliac artery, internal iliac artery, and external iliac artery “with complete occlusion of the popliteal artery below the knee and its branches.”
Northwell, the largest hospital system in New York State, invited all of the healthcare professionals it employs across 52 hospitals for free antibody tests, regardless of whether they’d had symptoms or a positive SARS-CoV-2 test. More than two-thirds signed up for the test and 13.7% of these people were seropositive, a JAMA research letter reports. Of the smaller subset who’d already had a positive PCR test, 6.5% had a negative antibody test.
It’s uncharacteristically impolite, but Canadians have started ratting out American license plates and in some cases damaging cars that appear to be “sneaking across the border” or detouring to tourist popular destinations instead of taking the most direct route through Canada to get to the state of Alaska, the New York Times reports. The Canadian border has been closed to Americans since March 31, 2020, unless they are dual citizens or have registered to pass through to the 49th state. Sorry.
Today's Dispatch was contributed by Shelley Wood.
August 6, 2020
A range of preexisting memory CD4+ T cells appear to cross-react with SARS-CoV-2 as well as with a number of common cold coronaviruses, suggesting that prior exposure to these viruses may provide some degree of immune reactivity. The study, published in Science, builds on earlier work suggesting that 40-60% of people never exposed to SARS-CoV-2 appeared to have T cells that reacted to the virus. “Having a strong T cell response, or a better T cell response may give you the opportunity to mount a much quicker and stronger response,” Alessandro Sette, PhD, who led the study with Daniela Weiskopf, PhD, commented in a press release. The finding may explain, at least in part, why some people experience a milder disease course than others.
In vaccine news, a mouse study published in Nature suggests that mice twice injected, 3 weeks apart, with the National Institutes of Health (NIH)-Moderna candidate vaccine (mRNA-1273) developed neutralizing antibodies. Later challenged with the SARS-CoV-2 virus either 5 or 13 weeks after the second injection, the animals appeared to be protected from viral replication in the lungs and nose. Novavax, meanwhile, announced top-line results from the first part of its Phase I /II trial of NVX-CoV2373 with and without an adjuvant, saying that the agent “was generally well-tolerated and elicited robust antibody responses numerically superior to that seen in human convalescent sera.”
At the same time, an editorial in the BMJ is sounding the alarm over the rush to market a COVID-19 vaccine, particularly since health authorities have expressed an interest in ‘vaccines’ that diminish illness severity as opposed to protecting against infection. “By setting the performance bar far lower in COVID-19 vaccine development than what would otherwise be acceptable for a new vaccine, we are also unwittingly redefining the very concept of a vaccine—from a long-term effective preventive public health tool to what could amount to a population-wide suboptimal chronic treatment,” Els Torreele, PhD, warns. “This might be good for business, but could prove fatal to global public health.”
The United States is the only affluent nation that has had “a severe, sustained outbreak of the virus,” says the New York Times, which attempts to map the missteps.
The US Food and Drug Administration (FDA) has sent a first warning letter to New Life International and a second to Fishman Chemical of North Carolina, LLC: both companies make chloroquine phosphate for aquarium fish. “Although neither company identified in today’s warning letters made claims about these products’ use by people, the agency is concerned that consumers may mistake, and have mistaken, unapproved chloroquine phosphate animal drugs for the human drug chloroquine phosphate,” the FDA says.
From May 1 through June 30, 2020, 15 people in the states of Arizona and New Mexico were hospitalized after ingesting hand sanitizers containing methanol, according to Morbidity and Mortality Weekly Report. Four patients remained hospitalized at the time of the study and four had been discharged with no signs of lasting harm—however, three patients were discharged with vision loss and four people had died.
Rahul K. Arora and colleagues, writing in the Lancet Infectious Diseases, describe the launch of a global SARS-CoV-2 seroprevalence dashboard called “SeroTracker.” The website “systematically monitors and synthesizes findings from hundreds of global SARS-CoV-2 serological studies” and “allows users to visualize seroprevalence estimates on a world map and compare estimates between regions, population groups, and testing modalities.”
A viewpoint in JAMA chronicles some of the recent attacks on public health officials in the United States, ranging from physical attacks and death threats to racist slurs and protests on the front lawns of health officers. “Amid a global pandemic that has already claimed more than 150,000 lives in the US, the nation needs strong public health leadership more than ever. Harassment of public health officials must stop.”
In a second JAMA viewpoint, Hallie C. Prescott, MD, and Timothy D. Girard, MD, propose that sepsis recovery may offer some clues as to how to COVID-19 survivors might recover—and need support.
Today's Dispatch was contributed by Shelley Wood.
August 5, 2020
The US Food and Drug Administration (FDA) has granted an emergency use authorization for the Impella family of left ventricular support systems in the setting of COVID-19. The authorization, covering the Impella 2.5, CP, CP with SmartAssist, 5.0, and 5.5 with SmartAssist, specifies that the devices can be used to provide temporary LV unloading and support in patients critical-care patients who are undergoing extracorporeal membrane oxygenation treatment.
Interleukin-6 (IL-6) receptor inhibitors sarilumab and tocilizumab appear to improve outcomes in patients with severe COVID-19, particularly when administered earlier in the disease course, researchers report in the International Journal of Infectious Diseases. Among 255 patients being treated at Boston Medical Center, patients with both lower and higher oxygen requirements were given the agents, with the former group seeing lower mortality, less likelihood of intubation, and greater likelihood of hospital discharge. “Our finding that prompt IL-6 receptor inhibitor treatment prior to the onset of critical disease is associated with reduced mortality from severe COVID-19 disease can be used to guide current clinical management while the medical community awaits more definitive results from randomized controlled trials,” investigators concluded.
The latest installment of the American College of Cardiology’s free Summer COVID-19 Education Series, airing Thursday, August 6 at noon ET, addresses the cardiovascular impact of COVID-19 on adults and children, including possible long-term impacts. Broadcasts are free but require registration.
The COVID-19 pandemic is disproportionately affecting women in academic medicine, who have had to assume more duties at home compared with men, particularly relating to childcare, an editorial in JAMA Surgery contends. During April and May 2020, the number of papers submitted with female first authors, senior authors, and corresponding authors all dropped by 4 to 7 percentage points as compared with the same period last year. Men in those same roles, by contrast, have seen absolute increases in the numbers of papers submitted. “While an immediate solution to this problem is not available, it would behoove academic institutions, funding agencies, and societies to recognize this increased burden on female parents and develop processes to try to alleviate these pressures,” the editorial concludes.
A prospective analysis of COVID-19 transmission in 15 schools and 10 day cares in Australia, published in Lancet: Child and Adolescent Health, suggests that coronavirus transmission was “extremely limited” in these settings during the first wave of the pandemic there. Stemming from a total of 16 students and 17 adult staff who first tested positive, only five (0.4%) additional secondary infections were recorded during two school terms. "COVID-19 transmission in schools appears to be considerably less than that seen for other respiratory viruses, such as influenza,” lead investigator Kristine Macartney, MD, is quoted in a press release.
Also in Lancet: Child and Adolescent Health, a modelling study attempts to quantify how much testing and contact tracing would be warranted to prevent a second wave of COVID-19 in the United Kingdom across different school reopening scenarios. “To prevent a second COVID-19 wave, relaxation of physical distancing, including reopening of schools, in the UK must be accompanied by large-scale, population-wide testing of symptomatic individuals and effective tracing of their contacts, followed by isolation of diagnosed individuals,” Jasmina Panovska-Griffiths, DPhil, and colleagues conclude.
Today's Dispatch was contributed by Shelley Wood.
August 4, 2020
One of the most baffling questions of the COVID-19 pandemic has been: why do some patients get so sick when others do not? Investigators led by Katie-May McLaughlin, writing in Diagnostics, believe they may have found a “missing link” in transferrin. The glycoprotein, selected from 200 candidate factors, is procoagulant, increases with age, occurs at higher concentrations in men than women, and is higher in SARS-CoV-2-infected cells. “Transferrin warrants further examination in ongoing clinic-pathological investigations,” they conclude.
One-third of patients positive for COVID-19 presenting with STEMI symptoms have angiographically normal coronary arteries; Takotsubo, myocarditis, microthrombi, and other triggers have all been well-documented. Writing in an early view publication in Catheterization and Cardiovascular Interventions, Fernando Rivero MD, and colleagues present a case of coronary spasm in patient with SARS-CoV-2 infection, using optical coherence tomography and invasive vasospasm to confirm the mechanism of injury.
An interview-based study of home healthcare workers in the five boroughs of New York City found that workers felt that their frontline work was “invisible” and risky—yet the training, protective supplies, and support materials they received varied widely—and that they needed to make “difficult trade-offs” between their work and personal lives. In JAMA Internal Medicine, an accompanying editorial notes that home-care workers are “underpaid and overwhelmingly women of color” doing critical work in the community. “Ultimately, we need to recognize that home health worker disparities are the result of structural racism and that this problem can be addressed through structural reforms,” its authors argue. “Just as COVID-19 has accelerated other aspects of medical and social progress, it is time to use the pandemic as an opportunity to engage in social justice for home-care workers, recognizing the value of their work by investing in their health and financial security.”
Despite the proliferation of commercial assays for detecting SARS-CoV-2 antibodies, their presence “has not yet been proven to confer meaningful or durable immunity to reinfection,” concludes a comprehensive, multisociety review published in CMAJ. Until more research can establish a link between immunity and antibodies, “serological testing should not be used to guide individual decisions about personal or occupational exposures, use of personal protective equipment and physical distancing,” the authors conclude.
Meanwhile, the US Food and Drug Administration (FDA) has issued new emergency use authorizations for two new antibody tests that are the first to display “an estimated quantity of antibodies present in the tested individual’s blood.” While not precise measurements, the results can help estimate the amount of antibodies produced in a given patient. In all, the FDA has authorized 198 COVID-19 tests to date: 161 molecular tests, 35 antibody tests, and 2 antigen tests, a press release notes.
An automated, web-based, symptom monitoring tool (Sara Alert; Mitra), which was introduced due to resource and staffing constraints by the Maine Center for Disease Control and Prevention to alert people that they’d been in contact with COVID-19, has been well-received: most of the people (96.4%) contacted by the system agreed to automated symptom monitoring, according to a study in Morbidity and Mortality Weekly Report. Of 1,622 enrolled, 11.7% ultimately developed COVID-19. “Automated tools, available in multiple languages and formats, might improve contact tracing programs and reduce resource needs, including staffing,” the authors conclude.
Today's Dispatch was contributed by Shelley Wood.
August 3, 2020
The pandemic has had a significant impact on active non-COVID-19 clinical research trials. In a paper published in the Journal of the American College of Cardiology, data from ClinicalTrials.gov show that 9% of all trials were reported as stopped and that the number halted per month increased significantly with time.
Over a 10-day period in June 2020, 44% of staff and campers at an overnight camp in Georgia tested positive for SARS-CoV-2—the kids hadn’t been required to wear masks. “Asymptomatic infection was common and potentially contributed to undetected transmission, as has been previously reported,” researchers write in MMWR.
Under the Rapid Acceleration of Diagnostics initiative, the National Institutes of Health (NIH) is giving nearly $250 million to seven companies currently working on lab-based and point-of-care testing for COVID-19. In a news release, the NIH said the efforts of these companies, which range from small start-ups to large publicly held organizations, will exponentially increase the nation’s testing capacity over the next few months.
In the United States and the United Kingdom, front-line healthcare workers have a threefold greater risk compared with the general population of testing positive for COVID-19, according to a study in the Lancet Public Health. The researchers say the risk “was especially high among Black, Asian, and minority ethnic healthcare workers and individuals in direct contact with patients with COVID-19 who reported inadequate [personal protective equipment (PPE)] availability or were required to reuse PPE.”
A brief report in JAMA Ophthalmology shows that despite triage systems to exclude patients with COVID-19 and enhanced cleaning protocols, viral material was found on examination room surfaces after a single day of patients being seen for eye exams.
Mandated Bacillus Calmette-Guérin (BCG) vaccination may be an effective means of reducing the spread of COVID-19, according to a paper published in Science Advances. In countries that mandate BCG vaccinations to reduce the risk of tuberculosis, the growth rate of COVID-19 cases was significantly slower than in countries without a mandate. The investigators say there is urgent need for randomized clinical trials of BCG.
Nearly 40% of older adults may have difficulty accessing telemedicine services with their physicians, according to a JAMA Internal Medicine report. In the cross-sectional study of 4,525 adults with an average age of 79 years, inexperience with technology was a primary reason for difficulty with video visits. The researchers suggest that telecommunication devices should be covered as a medical necessity, closed captioning for those with hearing impairment should be extended to virtual visits, and home visits should be considered in certain patient populations.
In the absence of a vaccine, a modeling study published in JAMA Network Open suggests that a highly specific, inexpensive screening test that would be administered every 1 to 7 days and give rapid results is needed before college campuses can safely reopen. The authors say they could not identify any circumstance under which symptom-based screening alone could sufficiently contain an outbreak among students at residential colleges.
Integrated, multilayered research efforts are needed to combat the biological and psychological mechanisms that contribute to COVID-19’s psychiatric fallout. A viewpoint in JAMA Psychiatry notes that coronaviruses can cause cognitive, emotional, neurovegetative, and behavioral dysregulation that may trigger immune activation followed by depression and suicidal behavior. Efforts are needed to address various aspects of the emergent psychiatric conditions associated with the virus and its impact, its authors say.
A study of 24 emergency departments (EDs) in Colorado, Connecticut, Massachusetts, New York, and North Carolina confirms a rapid decrease in visits beginning in early March 2020. The states saw declines in ED usage ranging from 41.5% in Colorado to 63.5% in New York. “These findings suggest that practitioners and public health officials should emphasize the importance of visiting the ED during the COVID-19 pandemic for serious symptoms, illnesses, and injuries that cannot be managed in other settings,” researchers conclude in JAMA Internal Medicine.