Lunchtime pandemic reading.
Standard disclaimer: this is a roundup of informative pieces I've read that interest me on the severity of the crisis and how to manage it. I am not a qualified medical expert in ANY sense; at best I am reasonably well-read laity. ALWAYS prioritize advice from qualified healthcare experts over some person on Facebook.
This is also available as an email newsletter at https://lunchtimepandemic.substack.com if you prefer the update in your inbox.
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On COVID-19 in kids. "Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in children are generally mild and non-fatal, there is increasing recognition of a paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2, also known as multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19, herein referred to as MIS-C, which can lead to serious illness and long-term side-effects
Clinical and laboratory features of MIS-C are similar to those of Kawasaki disease, Kawasaki disease shock syndrome, and toxic shock syndrome, but the disorder has some distinct features, and it needs a clear clinical and pathophysiological definition
MIS-C might be distinct from Kawasaki disease, with features including an age at onset of more than 7 years, a higher proportion of African or Hispanic children affected, and diffuse cardiovascular involvement suggestive of a generalised immune-mediated disease
Pathophysiology of MIS-C is still unclear and possible mechanisms include antibody or T-cell recognition of self-antigens (viral mimicry of the host) resulting in autoantibodies, antibody or T-cell recognition of viral antigens expressed on infected cells, formation of immune complexes which activate inflammation, and viral superantigen sequences which activate host immune cells
Most cases of MIS-C associated with COVID-19 were managed following the standard protocols for Kawasaki disease, with inotropic or vasoactive agents often required in patients with cardiac dysfunction and hypotension and anticoagulation also used frequently; clinical research is required to prove the effectiveness and safety of these treatments
The medium-term to long-term outcomes of MIS-C, such as the sequelae of coronary artery aneurysm formation, remain unknown and close follow-up is important"
Source: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30651-4/fulltext
Commentary: So much is unclear about how COVID-19 impacts children; in the less frequent severe cases, the side effects resemble disorders like Kawasaki disease, and treating it is still unknown. Medical professionals use existing therapies, but it's unclear whether those therapies work in a clinically proven way - or are even safe.
What does this mean? If a school or other environment where children congregate cannot be made safe, then the risks of COVID-19 complications such as MIS-C are higher. Whether or not a child dies, as with adults, those with severe complications may have long-lasting or even lifetime consequences. To that end, we have an obligation to offer the safest practical environments for ourselves and our kids until we have a working vaccine.
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Another tool in the toolkit. "Between March 1 and April 22, 2020, 764 patients with COVID-19 required support in the ICU, of whom 210 (27%) received tocilizumab. Factors associated with receiving tocilizumab were patients' age, gender, renal function, and treatment location. 630 patients were included in the propensity score-matched population, of whom 210 received tocilizumab and 420 did not receive tocilizumab. 358 (57%) of 630 patients died, 102 (49%) who received tocilizumab and 256 (61%) who did not receive tocilizumab. Overall median survival from time of admission was not reached (95% CI 23 days–not reached) among patients receiving tocilizumab and was 19 days (16–26) for those who did not receive tocilizumab (hazard ratio [HR] 0·71, 95% CI 0·56–0·89; p=0·0027). In the primary multivariable Cox regression analysis with propensity matching, an association was noted between receiving tocilizumab and decreased hospital-related mortality (HR 0·64, 95% CI 0·47–0·87; p=0·0040). Similar associations with tocilizumab were noted among subgroups requiring mechanical ventilatory support and with baseline C-reactive protein of 15 mg/dL or higher."
Source: https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(20)30277-0/fulltext
Commentary: As with dexamethasone and remdesivir, it's good to see another tool for mitigating mortality in the most severe COVID-19 cases. And as with those other two drugs, tocilizumab is absolutely something you should NOT take unless you have a severe case and it has been prescribed by a physician.
Over time, what we may find while the race for a vaccine is on is that we develop a robust toolkit to deal with the most severe outcomes, just as we've done with HIV. We have not created a cure or vaccine for HIV, but people who contract it can keep it at bay. That is a realistic possible outcome for COVID-19 in the short to medium term.
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In-person obstetrical care is safe as long as proper precautions are taken. "There was no meaningful association between the number of in-person health care visits and the rate of SARS-CoV-2 infection in this sample of obstetrical patients in the Boston area. Massachusetts had the third highest SARS-CoV-2 infection rate in the country during the spring 2020 surge, and the Boston area was particularly affected.
The findings from this obstetrical population who had frequent in-person visits to a health care setting and underwent universal testing for SARS-CoV-2 infection suggest in-person health care visits were not likely to be an important risk factor for infection and that necessary, in-person care can be safely performed. Limitations of this study include the restriction to obstetrical patients. Future studies are needed to determine whether these findings extend to other populations and health care settings."
Source: https://jamanetwork.com/journals/jama/fullarticle/2769678
Commentary: This study needs to be extended to other types of healthcare, but it's wonderful to see a clinical study showing no statistically significant risk of contracting COVID-19 for expecting mothers.
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How we must deal with flue season. "First, the approach to management of the 2 viruses is different. Influenza can be treated with a neuraminidase inhibitor or a cap-dependent endonuclease inhibitor, neither of which have antiviral activity against SARS-CoV-2. Remdesivir is available for treatment of COVID-19 under an Emergency Use Authorization, but because it is administered parenterally, it is reserved for hospitalized patients. It is also essential to confirm a diagnosis of COVID-19 to encourage early participation in clinical trials, especially for patients who may have contraindications to remdesivir. Many other treatments for COVID-19 are under investigation, including oral antivirals that could have important implications for outpatient management.
Second, the syndrome caused by each virus follows a different course. Patients with influenza typically experience most severe symptoms during the first week of illness, whereas patients with COVID-19 may experience a longer duration of symptoms with a peak during the second or third week of illness. Distinguishing between the viruses could allow clinicians to provide patients with anticipatory guidance about how symptoms are expected to evolve and can help identify complications later in the disease course.
Third, correctly identifying the virus has important infection control implications, including appropriate guidance regarding isolation and quarantine, return to school and work recommendations, and COVID-19 case identification and contact tracing.
As the 2020 respiratory virus season begins, any patient presenting with the nonspecific features of a respiratory viral infection should receive testing for SARS-CoV-2 at a minimum, a break from prior practice in which such patients were often managed based solely on clinical criteria. An additional layer of complexity is that coinfection with influenza and SARS-CoV-2 has been observed, so a positive result for one virus does not exclude infection with the other.7 It is not yet clear whether initial testing should include both viruses or whether influenza testing can be added after SARS-CoV-2 results return. The preferred diagnostic algorithm will depend on which diagnostic tests are locally available with careful consideration of test characteristics, cost, turnaround time, and supply chain issues.
Managing the pediatric population may differ because there are several unique characteristics of the viruses in children. Influenza is a source of significant morbidity and mortality in children, and individuals between the ages of 5 and 17 years are considered to play a critical role in propagating seasonal influenza outbreaks.8 In contrast, the disease trajectory of COVID-19 in children is typically mild, and children may be less likely to be infected or infect others.9 Therefore, while surveillance for pediatric spread of COVID-19 remains important to guide plans for school and daycare reopening, the health effects of COVID-19 in children is expected to be much lower than in older individuals."
Source: https://jamanetwork.com/journals/jama/fullarticle/2769676
Commentary: This double whammy can go either way. In places where countermeasures - masks, distancing, restrictions, and hygiene - are lax, the coming flu season will be made much worse by COVID-19 and vice versa. Medical practices will be dealing with both diseases, and a very real possibility exists that someone unlucky enough to contract both at the same time will have a substantially worse outcome.
In places where countermeasures are adhered to, we may see the flu season kneecapped, as we saw in Hong Kong in early 2020. People took immediate, near-universal precautions against COVID-19 and the flu season was abruptly cut short, because the countermeasures for COVID-19 also protect against the flu. Now that we know COVID-19 is also an airborne, aerosol virus, we have even greater overlap between the two diseases. Protecting against one protects against the other.
Thus, when you look at the COVID-19 maps of states and countries around the world, if a locale is faring poorly now with COVID-19 in the Northern Hemisphere, expect it to fare much worse in flu season. If it's faring well now and maintains vigilance, expect it to fare much better in flu season - and potentially even have a very short, mild flu season.
The choice is up to each of us individually. You're already in the habit of wearing a mask, watching your distance, washing your hands, and withdrawing from indoor spaces as quickly as possible. Those practices will protect you from the flu, too. Keep doing them.
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Who will be keeping kids home from school? "Weighted survey responses for key variables are presented in Figure 1. Notably, only 49% of participants said they would probably or definitely send their child to school if it opened in the fall, with 30% responding they would probably or definitely keep their child home. Forty percent of participants were more than moderately worried that they would catch the virus or that the health care system would not be able to protect their loved ones, and 34% were more than moderately worried about multisystem inflammatory syndrome in children. Confidence in schools was relatively modest, with 29% reporting they were confident or very confident that school could prevent the spread of COVID-19, 35% reporting school could provide enough social interaction for their child while enforcing social distancing, and 45% reporting that schools could meet their child’s academic needs with a modified schedule.
Factors associated with anticipated school attendance choice are shown in Figure 2. Key factors included income level, employment status, and job flexibility. Controlling for all other model variables, participants with lower incomes reported a higher likelihood of keeping their children home in the fall, with model-adjusted proportions of 38% of those making less than $50 000 per year in the “probably home” or “definitely home” categories vs 21% with incomes of $100 000 to $150 000 (difference, 17%; 95% CI, 9% to 26%). Those with flexible jobs were nearly as likely to keep their children home as those who were not employed (33% vs 40%; difference, 7%; 95% CI, −3% to 17%), whereas just 19% of those whose jobs were not flexible planned to probably or definitely keep their children home (difference from flexible jobs,−17%; 95% CI, −30% to -5%). Parents with children in grades 3 through 5 were more likely to plan to keep their children home than parents of high schoolers. Parents in households with vulnerable people were modestly more likely to plan to keep their children home. Race and ethnicity were not significantly associated with plans to keep children home. Together, family characteristics were associated with a modest proportion of the variability in plans to send children to school (R2 = 16%)."
Source: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2769634
Commentary: Lower income families are more likely to keep kids home during the pandemic. And it's not rocket surgery to understand why: with lower incomes typically comes worse health insurance and less resilience if a primary breadwinner falls ill. That's a sensible calculation where possible, to reduce risk as much as practical given the circumstances.
This also speaks to the desperate need to reform healthcare in the United States in particular so that healthcare is independent of employment.
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A reminder of the simple daily habits we should all be taking.
1. Wash/sanitize your hands every time you are in or out of your home for any reason. Consider also spraying the bottoms of your shoes with a general disinfectant (alcohol/bleach/peroxide) when you return home. Remember that cleaners are never to be ingested or injected.
2. Wear a mask when out of your home and if going to a high risk area, wear goggles. Respirators are back in stock at online retailers, too.
3. Stay home as much as possible. Minimize your contact with others and maintain physical distance of at LEAST 6 feet / 2 meters. Avoid indoor places as much as you can; indoor spaces spread the disease through aerosols and distance is less effective at mitigating your risks.
4. Get your personal finances in order now. Cut all unnecessary costs.
5. Replenish your supplies as you use them. Avoid reducing your stores to pre-pandemic levels in case an outbreak causes unexpected supply chain disruptions.
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Common misinformation debunked!
There is no genomic evidence at all that COVID-19 arrived before 2020 in the United States and therefore no hidden herd immunity:
Source:
There is no evidence SARS-CoV-2 was engineered, nor that it escaped a lab somewhere.
Source: https://www.washingtonpost.com/world/2020/01/29/experts-debunk-fringe-theory-linking-chinas-coronavirus-weapons-research/
Source: https://www.nature.com/articles/s41591-020-0820-9
Source: https://www.nationalgeographic.com/science/2020/05/anthony-fauci-no-scientific-evidence-the-coronavirus-was-made-in-a-chinese-lab-cvd/
There is no evidence a flu shot increases your COVID-19 risk.
Source: https://www.factcheck.org/2020/04/no-evidence-that-flu-shot-increases-risk-of-covid-19/
Source: https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa626/5842161
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A common request I'm asked is who I follow. Here's a public Twitter list of many of the sources I read.
https://twitter.com/i/lists/1260956929205112834
This list is biased by design. It is limited to authors who predominantly post in the English language. It is heavily biased towards individual researchers and away from institutions. It is biased towards those who publish or share research, data, papers, etc. I have made an attempt to follow researchers from different countries, and also to make the list reasonably gender-balanced, because multiple, diverse perspectives on research data are essential.