News Scan for Sep 29, 2021

News brief

Seven COVID-19 symptoms are more predictive of illness, study says

Seven COVID-19 symptoms can maximize detection of COVID-19 in the community, according to a large study published in PLOS Medicine yesterday that looked at data from England's REal-time Assessment of Community Transmission-1 (REACT-1) study.

Eight rounds of data collection from June 2020 to January 2021 occurred across 1,147,345 English residents aged 5 and older who received a COVID-19 test. From rounds 2 to 7, 0.4% of 979,079 were positive, and in round 8, which was dominated by the Alpha (B117) variant, 1.4% of 167,646 were positive.

By modeling COVID-19 positivity predictability on seven symptoms—loss or change of smell, loss or change of taste, fever, new persistent cough, chills, appetite loss, and muscle aches—the researchers found a 0.75 area under the curve (AUC) for rounds 2 through 7 and a 0.77 AUC for round 8.

Looking further at round 8, the researchers said that testing people in the community with at least one of the seven selected symptoms gave sensitivity, specificity, and positive-predictive values of 74%, 64%, and 9.7%, respectively. New persistent cough and sore throat was more associated with the Alpha variant, while loss or change of sense of smell was more predictive of the wild-type.

Using the seven symptoms to determine COVID-19 community testing eligibility would result in 30% to 40% of symptomatic individuals in England being eligible compared with the current 10%, which allows for only four of the seven, the researchers write. They add that if everyone eligible under these hypothetical conditions were to get tested, the country would detect 70% to 75% of positive cases.

"These findings suggest many people with COVID-19 won't be getting tested—and therefore won't be self-isolating—because their symptoms don’t match those used in current public health guidance to help identify infected people," said study author Paul Elliott, MBBS, PhD, in a PLOS press release.

"We believe that our approach, relying on these 7 symptoms, provides a reasonable balance between number of tests performed and detection rates in England, but alternative approaches could be envisaged depending on national population size, composition, and resources," write the researchers.
Sep 28 PLOS Med study
Sep 28 PLOS press release

Diabetes linked to increased COVID-19 hospitalization, death

Type 1 diabetes in those over 40 years of age is linked with higher COVID-related hospitalization risk, while type 2 diabetes is associated with higher mortality in COVID-hospitalized patients, according to a study in the Journal of Clinical Endocrinology & Metabolism and data presented at the European Association for the Study of Diabetes (EASD) annual meeting, respectively.

The first study looked at 767 US patients with COVID-19 and type 1 diabetes from April 2020 to March 2021. Compared with those younger than 40, those older had a 6.5-fold higher risk of COVID-19 hospitalization after adjusting for sex, insurance type, and A1c (a way to measure blood sugar; 95% confidence interval [CI], 4.0 to 12.2). Furthermore, the researchers found that, even after comorbidities were adjusted for, those who were 40 and older still had a 4.2-fold higher risk (95% CI, 2.3 to 7.8).

More than half of the cohort (54%) was 18 years or younger, while 32% were ages 19 to 40, and 14% were older than 40. No deaths occurred in the youngest age-group, while two occurred in the middle age-group and three in the oldest. Other associations included an increased likelihood of hospitalization if the patient had higher A1c values (odds ratio [OR], 1.5), if the patient were a minority (OR, 3.5), or if the patient had comorbidities (OR, 3.1).
Sep 28 J Clin Endocrinol Metab study

The second study involved 1,004 UK COVID-19 patients with diabetes and found that, within 7 days of hospitalization, mortality risk was 3.4 times higher for those older than 70 who had high C-reactive protein levels and 2.7 times higher for those younger than 70 with chronic kidney disease, a common long-term diabetes complication. Risk was also 2.5 times higher for those with type 2 diabetes compared with other types, and it was halved for those who had insulin infusion.

Body mass index, the researchers noted, was not associated with 7-day mortality.

The study period lasted from Jan 1 to Jun 30, 2020, with 24% dying by day 7 post-hospitalization and 33% by day 30. The researchers say that the cohort's old age (median, 74.1 years) and lower social status (45% lived in the most deprived areas of the nation) may have influenced the high death rate.
Sep 29 EASD abstract

Deer were transferred from CWD-infected farm in Wisconsin to Minnesota

Chronic wasting disease (CWD) was discovered at a Wisconsin farm that had sent five deer to Minnesota deer farms from 2016 to 2017, according to the Minnesota Department of Natural Resources (DNR) yesterday.

Two of the deer went to a Stillwater, Minnesota, farm in 2016, and when that went out of business, the deer were transferred to a farm in Grand Meadow, Minnesota, in early 2019. That farm went out of business as well, and so in late 2019, the two deer were transferred to a Wisconsin farm. The DNR is following up on CWD and living status.

The other three deer went to a Clear Lake, Minnesota, farm in fall 2017. Two were killed in early 2021 and had negative CWD tests. The third is alive, and the owner is awaiting payment prior to animal testing. In the meantime, the DNR says, the entire herd is being quarantined.

The Wisconsin farm had sold nearly 400 deer to 40 farms in seven states in the past 5 years; CWD was discovered on that farm this August. CWD is a fatal prion disease that affects the cervidae family, such as deer, moose, and elk, and it can be transferred through antler velvet, body fluids, and infected environments.
Sep 28 Minnesota DNR notice

China reports fatal H5N6 avian flu case

China reported another H5N6 avian flu case, its 21st of the year, which killed a 26-year-old woman, Hong Kong's Centre for Health Protection (CHP) said today.

The patient is from Guillan in Guangxi province, located in southern China. Her symptoms started on Aug 14, and she was hospitalized on Aug 19, where she died from her infection. Investigators found that she had contact with domestic poultry before she got sick.

China has now reported 45 human H5N6 cases, which are often severe or fatal, since the first was detected in 2014.

H5N6 is known to circulate in poultry, mostly in Asia. China and Laos are the only countries, however, that have reported human cases.
Sep 29 Hong Kong CHP statement

Human eastern equine encephalitis case recorded in New Jersey

Officials in New Jersey's Camden County have reported a human case of eastern equine encephalitis (EEE). The patient, a resident of Pine Hill, remains hospitalized.

"Eastern Equine Encephalitis is transmitted through the bite of an infected mosquito. Only a few human cases are reported each year, and the disease can't be passed directly from person to person," said County Commissioner Carmen Rodriguez, in a Camden County press release. "The Camden County Department of Health is continuing to work with the Mosquito Commission to ensure that additional spraying and testing will be conducted in the area."

EEE can cause a high fever, stiff neck, headache, lethargy, and general muscle pain. Symptom onset usually occurs 2 to 10 days after a mosquito bite. In one third of cases, infection is fatal. There is an EEE vaccine for animals, but none for humans.

The best way to protect against EEE, according to the Centers for Disease Control and Prevention (CDC), is using Environmental Protection Agency–registered insect repellents.
Sep 23 Camden County press release
CDC EEE page

Stewardship / Resistance Scan for Sep 29, 2021

News brief

Study finds CDC-based stewardship intervention is cost-effective

An intervention based on the Centers for Disease Control and Prevention (CDC) Core Elements of Outpatient Antibiotic Stewardship yielded cost savings at 10 outpatient Veterans Healthcare Administration (VHA) sites, researchers reported today in Infection Control & Hospital Epidemiology.

The intervention, implemented in September 2017, used a provider-directed audit feedback and academic detailing approach to promote appropriate diagnosis and treatment of uncomplicated acute respiratory tract infections (ARIs). To evaluate the cost-effectiveness of the intervention, researchers developed an economic simulation model from the health system perspective and compared antibiotic prescribing, appropriate treatment, adverse drug events, and hospitalizations at intervention sites and control (usual care) sites. The effectiveness measure was quality-adjusted life-years (QALYs). Costs included those related to treatment of ARIs and associated care, and costs incurred to implement the intervention.

A total of 16,712 and 51,725 patient visits occurred at the intervention and control sites, respectively. The proportion of ARI patient-visits with antibiotics prescribed at intervention sites was lower (62% vs 74%), appropriate treatment was higher (51% vs 41%), and hospitalization was lower (1.6% vs 1.9%) compared with control sites. The estimated intervention cost over a 2-year period was $133,604. The intervention had lower mean costs ($528 vs $565) and similar mean QALYs (0.869 vs 0.868) per patient compared with usual care. The cost savings were mainly driven by reductions in antibiotic prescribing and hospitalization.

"We conclude that the intervention compared to usual care is the preferred strategy for patients with uncomplicated ARI visits conditional on the decreased chance of hospitalization because of the intervention," the study authors write. "These findings may provide decision makers with a comparable benchmark for evaluating the antibiotic stewardship intervention."
Sep 29 Infect Control Hosp Epidemiol abstract

Medical record message linked to improved C diff antibiotic prescribing

In another study published today in the same journal, researchers reported that antibiotic prescribing for Clostridioides difficile infections (CDIs) improved at a health system in Michigan after a clinical decision support message was added to the electronic medical record.

Researchers at the Henry Ford Health System analyzed patient treatment for an initial CDI episode before and after a best practice advisory (BPA) was added to the electronic medical record to assist with antibiotic prescribing for CDI in the system's outpatient medical centers. The BPA alert stated "Vancomycin or fidaxomicin are preferred over metronidazole for C. difficile infection" per guidelines from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, and it displayed buttons to remove the order for metronidazole and place an order for a 10-day course of vancomycin.

The primary outcome of the study was the proportion of patients who received guideline-concordant CDI therapy. Secondary outcomes included clinical response, recurrence, and unplanned healthcare encounter.

A total of 189 patients were included in the study, with 92 treated before the BPA and 97 after the BPA. The BPA was accepted 23 of 26 times and was used to optimize the therapy of 16 patients in 6 months. After implementation of the BPA, guideline-concordant therapy increased (72% before vs 91% after), vancomycin prescribing increased (72.8% vs 86.6%), and metronidazole prescribing decreased (28.3% vs 10.3%). There was no difference in clinical response or unplanned encounter within 14 days after treatment initiation. Fewer patients after the BPA had CDI recurrence within 14 to 56 days of the initial episode (27% vs 7%).

"A targeted BPA is an effective stewardship intervention that may be especially useful in settings with limited antimicrobial stewardship resources," the study authors conclude.
Sep 29 Infect Control Hosp Epidemiol abstract