COVID-19 Scan for May 13, 2020

News brief

Choir practice in Washington state showed high COVID-19 attack rate

In a study yesterday in Morbidity and Mortality Weekly Report (MMWR), researchers describe a COVID-19 super-spreading event at a Washington state choir practice in March, which was attended by a symptomatic index patient and produced an attack rate of 53.3% to 86.7%.

The choir practice, conducted on Mar 10, lasted 2.5 hours and was attended by 61 people, 32 of were eventually confirmed to have COVID-19 and 20 of whom were probable secondary cases. Three patients were hospitalized, and two died. The index patient attended the practice with cold-like symptoms that had begun on Mar 7.

"The 2.5-hour singing practice provided several opportunities for droplet and fomite transmission, including members sitting close to one another, sharing snacks, and stacking chairs at the end of the practice," the authors, from Skagit County Public Health, said. "The act of singing, itself, might have contributed to transmission through emission of aerosols, which is affected by loudness of vocalization."

Over 75% of the confirmed cases were 65 and older, but most did not report underlying medical conditions. The authors said this super-spreading event highlights the need for physical distancing.
May 12 MMWR study

Rapid COVID-19 test shows low sensitivity in NY hospital study

A rapid coronavirus test that's being used in hospitals around the country, as well as in the White House, missed between a third and nearly a half of positive coronavirus samples at a New York City hospital, according to study published yesterday on the preprint server bioRxiv.

In the study, researchers from New York University (NYU) Langone Health and NYU Grossman School of Medicine evaluated the performance of the Abbott ID NOW COVID-19 assay—which can return results in as little as 5 to 13 minutes—against the Cepheid Xpert Xpress SARS-CoV-2 test, one of the two RT-PCR platforms used at NYU Langone Tisch Hospital to identify COVID-19 cases. The hospital was looking for a COVID-19 test that produces quicker results than the two tests, which take between 45 minutes and 3.5 hours to provide results.

Using nasopharyngeal samples transported in viral transport media (VTM) from patients with suspected COVID-19, the researchers found that the Abbott ID NOW test missed 5 of 15 positive results (33.3%) detected by the Cepheid Xpert Xpress test. When the researchers were told by Abbott that the assay performed best with dry nasal swabs obtained at the point of care, they then compared the results of dry nasal swabs tested in the Abbott ID NOW test with VTM samples from the same patients tested in the Cepheid Xpert Xpress test. But those results showed that the Abbott ID NOW test detected only 16 of 31 positive samples (51.6%) detected by the Cepheid Xpert Xpress, and the rest were falsely negative.

"Overall, our study revealed low sensitivity with high false negative results by Abbott ID NOW platform irrespective of use of viral transport media, which raises concern regarding the performance of the assay and its suitability as a diagnostic tool for symptomatic patients," the authors wrote. "The resolution could be to reflex all negative results for confirmation by a method with higher sensitivity. However, such [a] requirement would, except for positives, severely diminish the value of the rapid results of the assay."

The Food and Drug Administration issued an Emergency Use Authorization for the Abbott ID NOW test on Mar 27, and since then it has been shipped to all 50 states. The system is also used by the White House to test staff members.
May 12 bioRxiv study

GI symptoms part of early COVID-19 illness in kids

Nonrespiratory symptoms such as diarrhea can be the first symptoms of COVID-19 in children, according to a case series of five patients treated in a Wuhan hospital during China's epidemic. Researchers published their findings yesterday in Frontiers in Pediatrics.

The team described the clinical features of kids admitted to the hospital with nonrespiratory symptoms such as a kidney stone or head trauma who were then diagnosed with pneumonia on chest computed tomography and confirmed to have COVID-19.

Wenbin Li, MD, one of the study authors, said in a press release that it's easy to miss the diagnosis in the early stages of illness when the child has another illness. Four of five children in the case series had gastrointestinal (GI) symptoms as their first COVID manifestation. In kids with GI symptoms, especially those with fever and exposure to COVID-19, infection should be suspected, he said.

Li added that the GI symptoms may be related to the distribution of angiotensin-converting enzyme 2 (ACE2) receptors—located in both the lungs and the intestines—that the virus uses to enter cells.

The authors wrote that though more research is needed to confirm the findings, they hope the clinical profile they identified helps doctors quickly diagnose and isolate young patients with similar early symptoms.
May 12 Front Pediatr abstract
May 12 Frontiers press release

Study: Tool can help identify COVID-19 patients likely to need critical care

Chinese doctors have developed a clinical risk score and calculator that may help predict which hospitalized COVID-19 patients will become critically ill or die, according to a retrospective cohort study published yesterday in JAMA Internal Medicine study.

Using medical records from a development cohort of 1,590 patients and a validation cohort of 710 patients from 575 hospitals across China as of Jan 31, the physicians, along with the National Health Commission of China, identified 10 independent predictors of critical illness to create the risk score and web-based risk calculator. Patients were considered critically ill if they required admission to the intensive care unit or mechanical ventilation.

The predictors included abnormal chest radiographic findings, advanced age, cough with bloody discharge, shortness of breath, unconsciousness, multiple underlying illnesses, history of cancer, high neutrophil-to-lymphocyte ratio, high levels of lactate dehydrogenase (indicating tissue damage), and high levels of direct bilirubin (indicating liver damage). The authors described the accuracy of the calculator as "satisfactory."

According to American Thoracic Society guidelines, 24 of 1,590 patients in the development cohort (1.5%) had severe illness at hospital admission, while the remainder (1,566 [98.5%]) had mild illness. Overall, 131 patients (8.2%) eventually became critically ill. The death rate was 3.2%. In the validation cohort, 87 of 710 patients (12.3%) eventually became critically ill, and 8 (1.1%) died.

Mean age in the development cohort was 48.9 years, and 904 of 1,590 patients (57.3%) were men. Mean age in the validation cohort was 48.2 years, and 382 of 710 patients (53.8%) were men.

"Early detection of patients who are likely to develop critical illness is of great importance and may aid in delivering proper care and optimizing use of limited resources," the authors wrote.
May 12 JAMA Intern Med study

News Scan for May 13, 2020

News brief

Paper addresses liability concerns for antibiotic stewardship programs

A white paper published today in Infection Control and Hospital Epidemiology calls on antibiotic stewardship programs (ASPs) to take steps to address the potential legal implications of stewardship activities.

The paper, written by a team of legal and antibiotic stewardship experts, aims to address some of the concerns that ASPs, which are now required in most US hospitals, have about liability to patients they neither see nor examine. Although there is no legal precedent addressing liability and standards of care, and there have been no specific lawsuits filed involving ASPs, the question is whether ASPs put hospital staff at risk of litigation if they make errors that lead to patient harm. Using the results of a survey of healthcare professionals and analysis of case law, the experts provide an outline of the legal issues and strategies to address those issues.

Among the issues covered in the paper are the principles of medical liability in the context of ASPs, the existing regulatory landscape and whether it insulates ASPs from liability, documentation of ASP recommendations, clinical training of ASP personnel, the use of clinical practice guidelines, and what happens when treating teams do not accept ASP recommendations, or when ASP recommendations are incorrect.

To address these issues, the authors conclude that ASPs should work with hospital administration, treating teams, pharmacists, and other stakeholders to develop: (1) protocols to communicate and resolve differences with treating teams or other stakeholder, (2) documentation to provide the basis of recommendations as well as preserve the record of ASP involvement, and (3) standards for credentialing ASP team members based on experience or formal training.

"Regardless of specific circumstances, considering the best practices for program structure, interventions, and documentation is essential not only for risk mitigation, but also to optimize the quality of antibiotic prescribing and patient care," they write.
May 13 Infect Control Hosp Epidemiol abstract

Global life expectancy rises, but COVID-19 threatens progress

An annual snapshot of the world's health from the World Health Organization (WHO) shows that life expectancy and healthy life expectancy have increased, with the biggest gains in low-income countries, though the COVID-19 pandemic is threatening the progress.

In a statement, the WHO said its 2020 World Health Statistics report gauges progress with key health indicators, revealing progress and gaps in moving toward Sustainable Development Goals.

Low-income countries saw life expectancy rise 21%, or 11 years, between 2000 and 2016, compared with a rise of 4%, or 3 years, in higher-income countries. The WHO said better access to services to prevent and treat HIV, malaria, and tuberculosis, as well as neglected tropical diseases such as Guinea worm, helped move the needle for lower-income countries. Better maternal and child healthcare halved child mortality between 2000 and 2018 and also played a role.

However, the report also highlighted areas where progress has stalled, including immunization coverage, malaria prevention, and services for noncommunicable diseases. The WHO added that the uneven progress reflects unequal access to quality health services, with only one-third to one-half of the world's population able to access essential services in 2017. Cost of healthcare is another challenge, it said, noting that for 2020, about 1 billion people, about 13% of the global population, will spend at least 10% of their household budget on healthcare.

Samira Asma, DDS, MPH, the WHO's assistant director-general, said in the statement, "The COVID-19 pandemic highlights the need to protect people from health emergencies, as well as to promote universal health coverage and healthier populations to keep people from needing health services through multisectoral interventions like improving basic hygiene and sanitation."
May 13 WHO statement