Latest in Pulmonary News

Latest in Pulmonary News2019-02-15T07:28:32-05:00

Identification of SARS-CoV-2 RNA in Healthcare Heating, Ventilation, and Air Conditioning Units

Available information on Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmission by small particle aerosols continues to evolve rapidly. To assess the potential role of heating, ventilation, and air conditioning (HVAC) systems in airborne viral transmission, this study sought to determine the viral presence, if any, on air handling units in a healthcare setting where Coronavirus Disease 2019 (COVID-19) patients were being treated. The presence of SARS-CoV-2 RNA was detected in approximately 25% of samples taken from nine different locations in multiple air handlers. While samples were not evaluated for viral infectivity, the presence of viral RNA in air handlers raises the possibility that viral particles can enter and travel within the air handling system of a hospital, from room return air through high efficiency MERV-15 filters and into supply air ducts. Although no known transmission events were determined to be associated with these specimens, the findings suggest the potential for HVAC systems to facilitate transmission by environmental contamination via shared air volumes with locations remote from areas where infected persons reside. More work is needed to further evaluate the risk of SARS-CoV-2 transmission via HVAC systems and to verify effectiveness of building operations mitigation strategies for the protection of building occupants. These results are important within and outside of healthcare settings and may present a matter of some urgency for building operators of facilities that are not equipped with high-efficiency filtration.

 

Source:  Patrick F Horve, Leslie Dietz, Mark Fretz, David A Constant, Andrew Wilkes, John M Townes, Robert G Martindale, William B Messer, Kevin Van Den Wymelenberg medRxiv 2020.06.26.20141085;  doi: https://doi.org/10.1101/2020.06.26.20141085

Additional source: Lu J, Gu J, Li K, et al. COVID-19 Outbreak Associated with Air Conditioning in Restaurant, Guangzhou, China, 2020. Emerging Infectious Diseases. 2020;26(7):1628-1631. doi: 10.3201/eid2607.200764

Physical distancing interventions shows moderate reduction of incidence of coronavirus disease 2019 with caveats: natural experiment in 149

Objective : To evaluate the association between physical distancing interventions and incidence of coronavirus disease 2019 (covid-19) globally.

Design : Natural experiment using interrupted time series analysis, with results synthesised using meta-analysis.

Setting : 149 countries or regions, with data on daily reported cases of covid-19 from the European Centre for Disease Prevention and Control and data on the physical distancing policies from the Oxford covid-19 Government Response Tracker.

Participants : Individual countries or regions that implemented one of the five physical distancing interventions (closures of schools, workplaces, and public transport, restrictions on mass gatherings and public events, and restrictions on movement (lockdowns)) between 1 January and 30 May 2020.

Main outcome measure : Incidence rate ratios (IRRs) of covid-19 before and after implementation of physical distancing interventions, estimated using data to 30 May 2020 or 30 days post-intervention, whichever occurred first. IRRs were synthesised across countries using random effects meta-analysis.

Results : On average, implementation of any physical distancing intervention was associated with an overall reduction in covid-19 incidence of 13% (IRR 0.87, 95% confidence interval 0.85 to 0.89; n=149 countries). Closure of public transport was not associated with any additional reduction in covid-19 incidence when the other four physical distancing interventions were in place (pooled IRR with and without public transport closure was 0.85, 0.82 to 0.88; n=72, and 0.87, 0.84 to 0.91; n=32, respectively). Data from 11 countries also suggested similar overall effectiveness (pooled IRR 0.85, 0.81 to 0.89) when school closures, workplace closures, and restrictions on mass gatherings were in place. In terms of sequence of interventions, earlier implementation of lockdown was associated with a larger reduction in covid-19 incidence (pooled IRR 0.86, 0.84 to 0.89; n=105) compared with a delayed implementation of lockdown after other physical distancing interventions were in place (pooled IRR 0.90, 0.87 to 0.94; n=41).

Conclusions : Physical distancing interventions were associated with reductions in the incidence of covid-19 globally. No evidence was found of an additional effect of public transport closure when the other four physical distancing measures were in place. Earlier implementation of lockdown was associated with a larger reduction in the incidence of covid-19. These findings might support policy decisions as countries prepare to impose or lift physical distancing measures in current or future epidemic waves.

Source: Islam N, Sharp SJ, Chowell G, et al. Physical distancing interventions and incidence of coronavirus disease 2019: natural experiment in 149 countries. BMJ. 2020;370 :m2743.

Use of N95, Surgical, and Cloth Masks to Prevent COVID-19 in Health Care and Community Settings: Living Practice Points From the American College of Physicians

Regardless of the use of respiratory PPE, other procedures to reduce the transmission of SARS-CoV-2 infection should be followed, including maintaining physical distance, self-isolation, quarantine, frequent hand hygiene (using soap and water or alcohol-based hand rub), covering coughs and sneezes by using a bent elbow or paper tissue, refraining from touching the face, and frequent disinfection of frequently touched surfaces.

List 1: Use of N95 Respirators, Surgical Masks, and Cloth Masks in Community Settings

  • ACP discourages the use of N95 respirators by asymptomatic or symptomatic persons in community settings to reduce the risk for SARS-CoV-2 infection in the absence of any demonstrated benefit.
  • The decision to use surgical masks or cloth masks to reduce the risk for transmission of SARSCoV-2 infection among asymptomatic or symptomatic persons in community settings should follow community and statewide public health guidelines for mask use, which should take into account such factors as epidemiologic data (e.g. reproduction rate, daily case counts, hospitalizations, deaths) and local demographics (e.g. high-risk populations).
  • Potential harms associated with mask use include self-contamination, breathing difficulties, and a false sense of security that could potentially detract from taking other precautions, such as physical distancing.

List 2: Use of N95 Respirators, Surgical Masks, and Cloth Masks in Health Care Settings

  • All health care personnel in close contact*  with patients suspected or known to have COVID-19 should use N95 respirators in health care settings to reduce the risk for acquiring SARS-CoV-2 infection.
  • All patients with suspected or known COVID-19 should wear surgical masks in health care settings,
  • All health care personnel, patients, and visitors who are not in close contact with patients with suspected or known COVID-19 should use surgical masks in a health care setting to reduce the risk for transmission of SARS-CoV-2 infection.
  • Health care personnel should not use cloth masks in health care settings to reduce the risk for transmission of SARS-CoV-2 infection. Cloth masks are not considered PRE in health ca re settings, given the lack of evidence of their effectiveness against transmission of SARS-CoV-2 virus.

Reuse or Extended Use of N95 Respirators in Health Care Settings

No evidence is available on the effectiveness of reuse or extended use of N95 respirators in health care settings.

COVID-19 = coronavirus disease 2019; PRE = personal protective equipment; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.

* Close contact refers to being within 6 feet of a patient with COVID-19 or having direct contact with infectious secretions of a patient with COVID-19 (5).

Source : https://www.acpjournals.org/doi/10.7326/M20-3234

Promising Early Data from New COVID-19 Vaccine Studies Showing Safety and potential Efficacy

Around the world, more than 100 candidate vaccines against SARS-CoV-2 are in various stages of development and testing. On May 18, US biotech firm Moderna revealed the first data from a human trial: its COVID-19 vaccine triggered an immune response in people, and protected mice from lung infections with the coronavirus SARS-CoV-2. The current study was an open-label Phase I trial on 45 healthy adults. The participants received two doses four weeks apart of Moderna’s messenger RNA vaccine (mRNA-1273) at doses of 25 μg, 100 μg, or 250 μg. There was no comparison group, and, a significant limitation, the researchers did not screen the participants for SARS-CoV-2 infection by serology or polymerase chain reaction before enrollment. The study protocol calls for assessments at multiple points after each vaccination: 7, 14, 57, 119, 209, and 394 days. On days 1, 15, 29, 36, 43, and 57, the researchers tested each participant for binding antibodies and for neutralizing activity. Three of the 45 participants did not receive the second dose, one of whom developed urticaria and one who was in isolation for suspected COVID. On day 57, the researchers were able to detect binding and neutralizing antibodies with all three doses by 14 days after immunization with a peak at 28 days. The high-dose vaccine induced the greatest immunogenic responses but also the highest rate of adverse effects. Additionally, as we have observed with the new recombinant zoster vaccine, the second dose triggers more frequent adverse events: 54%, 100%, and 100% for each of the three doses, respectively. Fortunately, most of these were considered to be mild, and only three participants receiving the highest dose reported one or more serious adverse effects (21%). The adverse events included fever, arthralgias, injection site pain, headache, and chills. These are early and incomplete data from a small study with no control group, but the data provide hope that an effective vaccination is feasible.The mRNA-1273 vaccine induced anti–SARS-CoV-2 immune responses in all participants, and no trial-limiting safety concerns were identified.

Written by Henry C. Barry, MD, MS, on July 15, 2020. (Source: Jackson LA, Anderson EJ, Rouphael NG, et al. An mRNA vaccine against SARS-CoV-2—preliminary report [published online July 14, 2020]. N Engl J Med. 2020. https://www.nejm.org/doi/full/10.1056/NEJMoa2022483(www.nejm.org))

  1. Oxford-Astra-Zeneca Study : https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext
  2. Pfizer-BioNTech Study: https://www.medrxiv.org/content/10.1101/2020.06.30.20142570v1
  3. Regeneron Study: https://science.sciencemag.org/content/early/2020/06/15/science.abd0831/tab-pdf
  4. CanSino Biologics Study :https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31605-6/fulltext

Hydroxychloroquine and Azithromycin use in COVID-19 :Final chapter is not written yet

Over the last few months several studies has shown conflicting efficacy and safety of Hydroxychloroquine (HCQ) alone or in association with azithromycin or Doxycycline. Most recent data now published in International Journal of Infectious Diseases showing mortality benefit of HCQ alone or in association with Azithromycin in the treatment of COVID-19. In this observational study from the Henry Ford Health System in Detroit, investigators examined the in-hospital mortality of 2,541 consecutive hospitalized COVID-19 patients in four treatment categories: hydroxychloroquine (HCQ) plus azithromycin (AZM), either drug alone, or neither drug. They excluded patients who died in the first 24 hours after admission and another 10% of patients for whom final outcome data were unavailable (e.g., still hospitalized, left against medical advice, or transferred to another facility). The median time to follow-up was 28.5 days. Overall in-hospital mortality was 18.1% (95% CI, 16.6% to 19.7%). Mortality for patients taking HCQ+AZM was 20.1% (95% CI, 17.3% to 23.0%); for HCQ alone, 13.5% (95% CI, 11.6% to 15.5%); for AZM alone, 22.4% (95% CI, 16.0% to 30.1%); and neither drug, 26.4% (95% CI, 22.2% to 31.0%). In the Cox regression analysis that adjusted for age, gender, comorbid conditions, and disease severity, the hazard ratio for mortality was reduced 66% (p < 0.001) compared with the group receiving neither HCQ nor AZM. The authors report wide variations in the use of corticosteroids among the different treatment groups: 36% in those treated with neither medication, 39% of those receiving AZM alone, 74% of those treated with both, and 79% of those receiving HCQ alone. This is an observational study. These kinds of studies can find associations but are fairly weak in determining a causal link between an exposure and an outcome. In this study, the findings are inconsistent with other observational studies and with data we have from the few randomized trials that exist. Additionally, they found no effect of steroids in the outcome, which is at odds with other studies (e.g., see Research Brief from June 30 on the effects of dexamethasone from the RECOVERY Collaborative Group), at least in those with severe COVID. Observational studies are subject to all kinds of bias and are subject to alternative explanations for the findings. For example, about 25% of the patients had missing measures of disease severity and were excluded from the regression model. The co-treatment with steroids is likely to reflect differences in disease severity. Observational studies are also unable to account for the “hidden” factors involved in how physicians decide the treatments they choose based on other patient characteristics. Finally, the regression analysis took into account only factors the authors chose and could not address residual confounding. In a randomized trial, the known and unknown factors associated with the outcome of interest are evenly distributed between the intervention groups. Source: Arshad S, Kilgore P, Chaudhry ZS, et al.; Henry Ford COVID-19 Task Force. Treatment with hydroxychloroquine, azithromycin, and combination in patients hospitalized with COVID-19 [published online July 1, 2020]. Int J Infect Dis. https://www.ijidonline.com/article/S1201-9712(20)30534-8/fulltext(www.ijidonline.com))

Yale Treatment Algorithm for Hospitalized ADULTS with Non – Severe* COVID-19

Yale Ad-Hoc COVID-19 Treatment Team algorithms and protocols – multiple algorithms are assembled into a series of color-coded guidance sheets for hospitalist and internist to use. This algorithm is last updated on 4/27/20 and as such still include Hydroxychloroquine in treatment pathway, which is not a standard of care currently. However, rest of the treatment protocols still very helpful for hospitalized patients.

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Source : https://files-profile.medicine.yale.edu/documents/e91b4e5c-ae56-4bf1-8d5f-e674b6450847

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