Friday, May 1, 2020



Dr K K Aggarwal

President Confederation of Medical Associations of Asia and Oceania, HCFI and Past National President IMA

With regular inputs from Dr Monica Vasudev

790: Social distancing reduces COVID-19 infection: Evidence from China

Intense non-pharmaceutical interventions were put in place in China to stop transmission of the novel coronavirus disease (COVID-19). As transmission intensifies in other countries, the interplay between age, contact patterns, social distancing, susceptibility to infection, and COVID-19 dynamics remains unclear. To answer these questions, we analyze contact surveys data for Wuhan and Shanghai before and during the outbreak and contact tracing information from Hunan Province.

Daily contacts were reduced 7-8-fold during the COVID-19 social distancing period, with most interactions restricted to the household.

We find that children 0-14 years are less susceptible to SARS-CoV-2 infection than adults 15-64 years of age (odd ratio 0.34, 95%CI 0.24-0.49), while in contrast, individuals over 65 years are more susceptible to infection (odd ratio 1.47, 95%CI: 1.12-1.92). Based on these data, we build a transmission model to study the impact of social distancing and school closure on transmission.

We find that social distancing alone, as implemented in China during the outbreak, is sufficient to control COVID-19.

While proactive school closures cannot interrupt transmission on their own, they can reduce peak incidence by 40-60% and delay the epidemic.

Juanjuan Zhang J , Maria Litvinova, Yuxia Liang , et al. Changes in contact patterns shape the dynamics of the COVID-19 outbreak in China. J. Zhang et al., Science 10.1126/science.abb8001 (2020).

791: Rare inflammatory syndrome seen in US child with Covid-19

(CNN)US doctors say they may have seen a possible complication of coronavirus infection in a young child: a rare inflammatory condition called Kawasaki disease.

National Health Service England sent an alert to doctors and on Sunday the Paediatric Intensive Care Society tweeted it out to members. It warned about a small increase in cases of critically ill children with "common overlapping features of toxic shock syndrome and atypical Kawasaki disease with blood parameters" with some children testing positive for Covid-19.

There have also been some reports in Italy and Spain.

Kawasaki disease causes inflammation in the walls of the arteries and can limit blood flow to the heart. It is usually treatable and most children recover without serious problems, but it can be deadly. No one knows what causes Kawasaki disease, but some studies have pointed to a link between viruses or a bacterial infection. {Journal Hospital Pediatrics}.

792: In the first three weeks after symptom onset, the majority of RT-PCR results were positive for SARS-CoV-2.
 From week three onward, negative results increased. All tests were negative at week six after symptom onset.
The rate of positive results was highest at week one (100%), followed by 89.3%, 66.1%, 32.1%, 5.4% and 0% at weeks two, three, four, five and six, respectively.
Patients were further divided into non-prolonged and prolonged shedding groups based on nucleic acid conversion time (up to or more than 24 days). Patients with longer viral shedding tended to be older and were more likely to have comorbidities such as diabetes and hypertension.

793:  Protect yourself and your pets: CDC says keep animals 6 feet apart
While the main way the virus spreads is from person to person, transmission between animals and humans can't be ruled out until more testing is done. When you take your dog on a walk, don't let your social distancing guard down. The same goes for your indoor/outdoor cat. According to the Centers for Disease Control and Prevention, it's best to take precautions and keep your pets away from other people and animals at this time. Not only should you maintain a physical distance of at least 6 feet from others, but the CDC now says your animals should maintain that distance as well.

794: In the U.S. multiple animals, including a family's pug in North Carolina, two pet cats, and five tigers and three lions at the Bronx Zoo in New York have tested positive for COVID-19. Two pet dogs and a pet cat in Hong Kong also tested positive.

But the CDC said there's no evidence that animals play a significant role in spreading the novel coronavirus, SARS-CoV-2, that causes COVID-19. But while the main way the virus spreads is from person to person, transmission between animals and humans can't be ruled out until more testing is done. Dr. McCarthy says during the COVID-19 outbreak people should not let their pets interact with anyone - two-legged or four-legged - outside of the household.  As tempting as it is, avoid petting other people's dogs. For now, hold off on bringing your pups to dog parks and letting them run around off leash. As you've heard hundreds of times by now, wash your hands and maintain good hygiene, around people and around animals.

795: Two rare neurologic conditions in patients hospitalized with COVID-19

 A 50-year-old man developed Miller Fisher syndrome and a 39-year-old man developed polyneuritis cranialis. Both are variants of Guillain-BarrĂ© syndrome (GBS), which physicians in China and Italy also linked to COVID-19 infection [ Medscape]

760: Remdesivir now ‘standard of care’ for COVID-19

Hospitalized patients who had advanced COVID-19 with lung involvement and who received the antiviral agent remdesivir (Gilead Sciences) recovered faster than did similar patients who received placebo, according to a preliminary data analysis from a U.S.-led randomized, controlled trial.

The interim results, discussed in the press conference and in a NIAID press release, show that time to recovery (i.e., being well enough for hospital discharge or to return to normal activity level) was 31% faster for patients who received remdesivir than for those who received placebo (P < .001).

The median time to recovery was 11 days for patients treated with remdesivir, compared with 15 days for those who received placebo. Results also suggested a survival benefit, with a mortality rate of 8.0% for the group receiving remdesivir and 11.6% for the patients who received placebo (P = .059).

The study, known as the Adaptive COVID-19 Treatment Trial (ACTT), is the first clinical trial launched in the United States to evaluate an experimental treatment for COVID-19. It is being conducted at 68 sites – 47 in the United States and 21 in countries in Europe and Asia.

761:  The Infectious Disease Society of America has released new guidelines on the use and reuse of personal protective equipment

The guidelines contain the following eight recommendations for encounters with suspected or confirmed COVID-19 patients:

  1. Either a surgical mask or N95 (or N99 or PAPR [powered & supplied air respiratory protection]) respirator for routine patient care in a conventional setting.

  1. Either a surgical mask or reprocessed respirator as opposed to no mask for routine care in a contingency or crisis setting.

  1. No recommendation on the use of double gloves vs. single gloves.

  1. No recommendation on the use of shoe covers for any setting.

  1. An N95 (or N99 or PAPR) respirator for aerosol-generating procedures in a conventional setting.

  1. A reprocessed N95 respirator as opposed to a surgical mask for aerosol-generating procedures in a contingency or crisis setting.

  1. Adding a face shield or surgical mask as a cover for an N95 respirator to allow for extended use during respirator shortages when performing aerosol-generating procedures in a contingency or crisis setting. This recommendation carries a caveat: It assumes correct doffing sequence and hand hygiene before and after taking off the face shield or surgical mask cover.

  1. In the same scenario, adding a face shield or surgical mask over the N95 respirator so it can be reused, again assuming the correct sequence for hand hygiene.

762:  SGLT2 and COVID

A just-launched study of the type 2 diabetes agent dapagliflozin in patients with mild-moderate COVID-19 is raising eyebrows, given that several expert groups have advised that drugs in this class — the sodium-glucose cotransporter 2 (SGLT2) inhibitors — be stopped in all patients hospitalized with COVID-19 due to the increased risk for diabetic ketoacidosis (DKA).

763: a Third of COVID-19 Hospital Patients May Die
A third of patients in hospital with COVID-19 may be dying, according to preliminary UK research. The preprint also found that being male or obese reduced chances of survival from the disease. More than half of patients mechanically ventilated are dying, the authors said. The prospective observational cohort study, which has not been peer reviewed, was carried out by a consortium of researchers, known as ISARIC4C, and was led by the University of Liverpool, University of Edinburgh, and Imperial College London (ICL).

764: Increase in out-of-hospital cardiac arrests in Italy linked to COVID-19                                                                                              

A study published in The New England Journal of Medicine showed a correlation between out-of-hospital cardiac arrests and COVID-19 in Lombardy, Italy.  Using the Lombardia Cardiac Arrest Registry, Enrico Baldi, MD, University of Pavia, Pavia, Italy, and colleagues compared out-of-hospital cardiac arrests that occurred in the provinces of Lodi, Cremona, Pavia, and Mantua during the first 40 days of the COVID-19 outbreak (February 21-March 31, 2020) with those that occurred during the same period in 2019 (February 21-April 1, 2019 to account for the leap year). 

During the 2020 study period, a total of 9,806 cases of COVID-19 were reported. During this period, 362 cases of out-of-hospital cardiac arrest were identified, compared with 229 cases during the same period in 2019 -- a 58% increase. Increases of various magnitudes in the numbers of cases of out-of-hospital cardiac arrest were seen in all 4 provinces. 

Of the 362 cases of out-of-hospital cardiac arrest in 2020, 103 were suspected to have or had received a diagnosis of COVID-19 (87 and 16 patients, respectively). These numbers account for 77.4% of the increase in cases of out-of-hospital cardiac arrest observed in these provinces in 2020.

“The cumulative incidence of out-of-hospital cardiac arrest in 2020 was strongly associated with the cumulative incidence of COVID-19 (Spearman rank correlation coefficient, 0.87; 95% confidence interval, 0.83-0.91; P< 0.001), and the increase in the number of cases of out-of-hospital cardiac arrest over the number in 2019 followed the time course of the COVID-19 outbreak,” the authors wrote. 

765: COVID-19: Anticoagulation Recommended Even After Discharge

"I have never, ever, ever seen such high levels of D-dimer in any of the hundreds of other patients with venous thrombosis that I've seen over the past 15 years," said Behnood Bikdeli, MD, of NewYork-Presbyterian Hospital/Columbia University Irving Medical Center in New York City. "It's just mind-blowing."

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