COVID-19 Alaska Clinical Update, Sept. 24
Alaska DOH sent this bulletin at 09/24/2020 07:36 PM AKDT
Thursday, September 24
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The above scatter plot is from Admiral Giroir, the US Assistant Secretary for Health. Alaska's case rates are near the middle compared to other states. While Alaska is doing more testing than mostother states, we are still looking to expand testing and improve access to testing so Alaskans do not have to hesitate to get tested when they experience even one mild symptom. We are seeing many infections in both children and adults present with one or more very mild symptoms, so clinicians are encouraged to test at the first sign of any one or more new COVID-19 symptom (headache, runny nose or nasal congestion, sore throat, new loss of taste or smell, fatigue, muscle or body aches, nausea, vomiting, diarrhea, fever, chills, cough, shortness of breath, difficulty breathing).
6.7 million Americans have been diagnosed with COVID-19 so far and more than 201,000 deaths are now reported.
More than 31 million COVID-19 cases have been diagnosed worldwide. Currently, over 973,000 deaths are reported worldwide, and the total is likely to surpass one million by early October. |
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ARDS in COVID-19, reviewed A JAMA Internal Medicine review discussed current evidence for management of ARDS in patients with severe COVID-19. Authors note in particular that meticulous supportive care and lung-protective ventilation improves outcomes. They also recommend a conservative fluid strategy including aggressive diuresis if necessary in patients who are not in shock, minimizing sedation and neuromuscular blockade when possible, and considering prone positioning for patients with a P/F ratio <150. They suggest considering ECMO if profound hypoxemia or severe respiratory acidosis persist despite interventions. Authors note that awake proning has become a more common practice in patients with early, nonintubated respiratory failure and is supported by small studies, while clinical trials are ongoing.
In terms of pharmacologic treatment of COVID-19, remdesivir for hospitalized patients shortens the time to recovery, but the utility in patients requiring mechanical ventilation is uncertain. Dexamethasone also confers a survival benefit in severe or critical COVID-19. Authors comment that while many patients have been treated with IL-6 blockers amid concerns for a cytokine storm, limited data available indicate that IL-6 levels in patients with COVID-19 are ‘orders of magnitude lower’ than in patients with cytokine release syndrome and in some cases lower than patients with ARDS not associated with COVID-19, warning that there are no substitutes or shortcuts for high quality randomized clinical trials.
Risk of COVID-19 in healthcare workers
A Lancet prospective observational cohort study conducted in the UK and US from late March to late April 2020 enrolled over 2 million people, including nearly 100,000 front-line healthcare workers. Most healthcare workers and nearly all non-healthcare workers were located in the UK. The average age of both groups was early 40s, with similar distributions of age and race, although healthcare workers enrolled were 83% female compared to 63% of the general community. In total, 5545 study participants reported receiving a positive COVID-19 test during that time. Health care workers reported a positive COVID-19 test more frequently than the general community, with a hazard ratio of 11.61 (95%CI 10.93-12.33). Authors applied an adjustment to account for differences in testing frequency and selection bias and concluded that the adjusted hazard ratio was 3.4 (95% CI 3.37-3.43), corresponding to more than a threefold risk of a positive COVID-19 test in healthcare workers compared to the general community.
This study was not designed to distinguish between infections acquired at work and infections acquired through exposures outside of work, however authors note that healthcare workers reporting PPE reuse had an increased risk of a positive COVID-19 test compared to healthcare workers reporting adequate PPE (adjusted hazard ratio 1.46, 95% CI 1.21-1.76), particularly in the subset of healthcare workers working with patients with suspected or documented COVID-19 (HR 3.2[2.2-4.6] and 5.1[3.9-6.6] respectively).
Authors also reported hazard ratios by work setting. Among those, inpatient work carried a hazard ratio of 24.3 (21.2-26.3) in their analysis, followed by nursing homes (16.2 [13.4-19.7]) and outpatient hospital clinics (11.2 [8.4-14.9]). A CDC seroprevalence study of healthcare workers was conducted in Detroit in May and June, 2020, finding that 6.9% of 16,403 enrolled healthcare workers had SARS-CoV-2 antibodies. Major factors increasing the odds of seropositivity in adjusted analyses included household members with COVID-19 (odds ratio 6.18 [95% CI 4.8-7.9]], working as a nurse assistant (1.88 [1.24-2.83]) or nurse (1.52 [1.18-1.95]), and working in an emergency department (1.16 [1.24-2.83]). Consistently using N95 respirators (0.83 [0.72-0.95]) and surgical facemasks (0.86 [0.75-0.98]) decreased the likelihood of seropositivity.
Data in AK healthcare workers
260 cases of COVID-19 were reported in Alaskans working in healthcare since the beginning of the pandemic. Of these, 51% likely were exposed to the virus at work, while 29% acquired the virus because of a contact within their household or through community spread, and 3% acquired the virus through out of state travel. The remaining 17% did not have a known exposure that could be determined. These data may not capture all cases in Alaska health care workers since not all cases have an occupation identified.
Healthcare workers included in these data are physicians, nurses, pharmacists, dentists, nursing aides, EMTs, first responders, behavioral health professionals, and others working in inpatient and outpatient health care. 29% of the 260 cases reported did not have an occupation specified and listed only healthcare. Of the 260 healthcare workers with COVID-19, approximately 20% worked in a hospital, 23% in a long term care, rehab or assisted living facility, 13% in outpatient medicine, dentistry or therapies, 14% in another setting and 30% did not have a work site specified. Of the 260 cases in healthcare workers identified, 8 required hospitalization. There were no deaths reported.
An elastic virus
Atomic force microscopy of SARS-CoV-2 virions, described in a preprint article, showed a highly flexible structure that was able to collapse when a probe tip pushed its surface against its opposite wall and rebound intact. The spike proteins on the surface, which varied in number, displayed rapid rotational motion. Researchers exposed the virions to high temperatures, which did not compromise the global structure but did denude the viral surface of spike proteins. Spike proteins are necessary for SARS-CoV-2 to enter cells, meaning that increased temperature could impair infectivity through loss or denaturation of spike proteins.
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