COVID-19 Alaska Clinical Update
Wednesday, September 8, 2021
At 12 months after hospitalization due to COVID-19, 49% of patients have at least 1 residual symptom
This longitudinal cohort study of 1,276 patients who survived hospitalization for COVID-19 infection in Wuhan, China between January-May 2020 investigated sequelae of hospitalization at 6 and 12-months. At the 12-month visit, 49% of patients had at least sequalae symptom. 30% of participants reported dyspnea at 12 months and 26% reported anxiety or depression. 88% of patients who had been employed before COVID-19 had returned to their original work at 12 months. When participants were matched with controls who were never infected with SARS-CoV-2, the participants had more problems with mobility, pain or discomfort, and anxiety or depression, and had more prevalent symptoms than did controls.
Surveillance testing with at-home direct antigen rapid tests (DART) was more than 96% sensitive for diagnosing COVID-19 infection within 3 days of symptom onset
In this JAMA research letter, 257 coworking employees in Boston performed twice-weekly at-home DART testing and RT-PCR testing to evaluate the feasibility, sensitivity, and specificity of an at-home antigen test. A total of 15 workers contracted COVID-19. DART sensitivity was 96.3% within 0-3 days of symptoms with specificity of 97.1%. Most of the positive participants reported that they did not recognize symptoms of COVID-19 until they received a positive result. The study was funded by and many of the authors declared financial relationships with the three companies overseeing the research and production of the DART device studied.
Mask wearing intervention in Bangladesh villages associated with 11% relative reduction in COVID in villages with high mask adoption
In this cluster randomized trial of community level mask promotion in rural villages in Bangladesh from November 2020 to April 2021 more than 340,000 individuals were randomized at the village and household level to receive free masks, information on masking, role modeling by community leaders, and in-person reminders for 8 weeks. On reassessment 5 months after intervention, mask wearing remained 10% higher in the intervention group than the control group. In villages that were randomized to receive surgical masks, there was a relative reduction of COVID seroprevalence of 11.2% overall and 34.7% among individuals age 60 years and older.
*This article has not gone through peer review and is in pre-print status. It may have not been finalized by authors, might contain errors, and report information has not yet been accepted or endorsed in any way by the scientific or medical community.
Updated household secondary attack rate of SARS-CoV-2 is almost 19%
This updated systematic review and meta-analysis added data from 37 new studies to a previous review of 50 studies to evaluate the overall household secondary attack rate for SARS-CoV-2 stratified by demographics, symptoms, study location, and variant. The secondary attack rate (SAR) is the number of cases among contacts of primary case divided by the total number of contacts x 10. The previous review had calculated an overall household SAR of 16.6%. The updated overall household SAR in this review is 18.9%. There was an increase in household transmission over time, which may be due to improved diagnostic procedures and tools, longer follow-up, more contagious variants, and different study locations. Results from subgroup analyses were similar to those reported in the prior analysis; however, the SAR was higher to contacts with comorbidities (50.0%) compared with previous findings and the estimated household SAR for the Alpha variant was 24.5%.
AMA, APhA, ASHP call for immediate end to prescribing, dispensing, and use of ivermectin for COVID-19
On September 1, the American Medical Association (AMA), American Pharmacists Association (APhA), and American Society of Health-System Pharmacists (ASHP) released a joint statement strongly opposing the ordering, prescribing, or dispensing of ivermectin to prevent or treat COVID-19 outside of a clinical trial. The statement says, “We are alarmed by reports that outpatient prescribing for and dispensing of ivermectin have increased 24-fold since before the pandemic and increased exponentially over the past few months…we are urging physicians, pharmacists, and other prescribers — trusted healthcare professionals in their communities — to warn patients against the use of ivermectin outside of FDA-approved indications and guidance”
Please see the “Ivermectin” section below for more information on this topic including the CDC’s recent Health Advisory.
AMA releases statement on the ethics of prescribing medications for “off label” use during a pandemic
On August 31 the American Medical Association (AMA) released a statement providing guidance for physicians about using medications “off label” during the COVID-19 pandemic. The statement mentions some of the various “off label” therapies that have been suggested, such as ingesting household cleaning products, hydroxychloroquine, and ivermectin but also mentions practice such as prescribing vaccines for children younger than 12 years for whom the vaccine has not yet been authorized. This provides concrete recommendations that “Physicians must explicitly seek the patient’s consent to the off-label use” and candidly disclose how the therapy differs from the standard approach, why the physician is recommending it, the known risks and benefits, experience with innovative use, and any conflicts of interest the physician may have. The AMA’s Code of Medical Ethics also says, “Responsibly prescribing an approved medication for a novel, off label use requires that the physician reflect critically on the evidence that is available, seek input from knowledgeable colleagues or other medical professionals, and attend carefully to minimizing the risks to the patients for whom the physician intends to prescribe for an unapproved use”
CDC Morbidity and Mortality Weekly Reports:
Among adolescents aged 0-17 years, COVID-19 cases, ED visits, and hospitalizations increased from June-August 2021
In this MMWR, the authors examined COVID-19 cases, ED visits for COVID-19, and hospitalizations for COVID-19 for adolescents aged 0-17 years from August 1, 2020 to August 27, 2021. Cases, ED visits, and hospitalizations increased in June-August 2021. For a two week period in August, COVID-19–associated ED visits and hospital admissions for pediatric patients with COVID-19 were highest in Southern states that had the lowest vaccination coverage and lowest in states with the highest vaccination rats. The percentage of COVID-19 hospitalizations resulting in ICU admission has remained near 20% since Delta became the predominant SARS-CoV-2 variant.
Pediatric COVID-19 hospitalization rates increased five-fold during late June – mid-August 2021 coinciding with rise of Delta variant
This MMWR reports data from the COVID-NET surveillance network of 99 counties across 14 states regarding COVID-19-associated hospitalization for children and adolescents. Weekly hospitalization rates rose rapidly during late June to mid-August 2021 among U.S. children and adolescents aged 0–17 years; by mid-August, the rate among children aged 0–4 years was nearly 10 times the rate 7 weeks earlier. This increase coincides with widespread circulation of the highly transmissible Delta variant. Among adolescents aged 12–17 years, hospitalization rates were approximately 10 times higher in unvaccinated compared with fully vaccinated adolescents, indicating that vaccines were highly effective at preventing serious COVID-19 illness in this age group. Since March 2020, approximately one in four hospitalized children and adolescents with COVID-19 has required intensive care; this proportion did not significantly change during the rise of the Delta variant.
RECURRENT TOPICS
Providing COVID-19 vaccinations
We recommend that all healthcare providers outreach to their patients who are immunocompromised and are candidates for a third vaccine dose. A third dose of mRNA COVID vaccine is recommended in certain immunocompromised individuals, specifically solid organ transplant recipients or those who are diagnosed with conditions that are considered to have an equivalent level of immunocompromise (active lymphoma/leukemia treatment, stem cell transplant recipient, active treatment with high-dose corticosteroids).
If you are interested in providing the COVID-19 vaccine in your office or clinic, please visit the COVID-19 Vaccination Program Provider Enrollment page. If you have additional questions, please email Matthew Bobo at matthew.bobo@alaska.gov
Monoclonal Antibodies
Monoclonal antibody treatment for COVID-19, REGEN-COV (casirivimab and imdevimab), has been approved to treat mild-moderate COVID-19 and for post-exposure prophylaxis of COVID-19 in individuals age 12 years and older who are at high risk for progression to severe COVID-19.
NIH updates guidance on providing MAB when there are logistical constraints
Currently there are no shortages of monoclonal antibodies, however logistical constraints (e.g., limited space, not enough staff who can administer therapy) can make it difficult to administer these agents to all eligible patients. The NIH recently updated its guidance to address situations where it is necessary to triage eligible patients if there is a limited supply. The new guidance recommends:
- Prioritizing the treatment of COVID-19 over post-exposure prophylaxis of SARS-CoV-2 infection.
- Prioritizing the following groups over vaccinated individuals who are expected to have mounted an adequate immune response:
- Unvaccinated or incompletely vaccinated individuals who are at high risk of progressing to severe COVID-19
- Vaccinated individuals who are not expected to mount an adequate immune response (e.g., immunocompromised individuals).
Providers should use their clinical judgment when prioritizing treatment or post-exposure prophylaxis in a specific situation. When there are no logistical constraints for administering therapy, these considerations should not limit the provision of anti-SARS-CoV-2 monoclonal antibodies.
If you are interested in providing monoclonal antibody therapy for COVID-19 in your office or clinic, please refer to this guide from the U.S. DHSS, and then send an email to Coleman Cutchins (coleman.cutchins@alaska.gov) and CJ Kim (cj.kim@alaska.gov) for local assistance.
For the latest recommendations, check out the CDC webpage on Monoclonal Antibodies for High-Risk COVID-19 patients and COVID-19 Monoclonal Antibody Resources for Healthcare Providers.
Ivermectin
On August 26, the CDC issued a Health Advisory about the increase in ivermectin prescriptions during the 2021 summer and an associated rise in the number of calls to poison centers reporting overdoses or adverse effects.
According to the Merck, the drug company that manufactures ivermectin, there is:
- No scientific basis for a potential therapeutic effect against COVID-19 from pre-clinical studies;
- No meaningful evidence for clinical activity or clinical efficacy in patients with COVID-19 disease, and;
- A concerning lack of safety data in the majority of studies.
A Cochrane Review published July 28 concluded, the “reliable evidence does not support the use of ivermectin for treatment or prevention of COVID‐19.” In addition, the FDA has recently created a webpage further explaining why you should not use ivermectin to treat or prevent COVID-19 and the potential harms of taking a veterinary formulation of this mediation. Infectious Disease Society of America (IDSA) guidelines do not recommend ivermectin.
Post-acute Sequelae of COVID-19 (PASC)
Risk of PASC appears to be nearly halved for individuals with vaccine breakthrough infections compared to unvaccinated individuals
This prospective, community-based, nested, case-control study used self-reported data from UK-based, adult users of the COVID Symptom Study mobile phone app. The study matched individuals who contracted COVID after vaccination with individuals who contracted the virus before vaccination to compare risk of hospitalization, prolonged symptoms, and PASC. The research team found that the odds of COVID-19 symptoms persisting for 28 days or more among those who were fully vaccinated was approximately halved (Odds Ratio 0.51) compared with unvaccinated controls. Compared with unvaccinated controls, individuals after their first or second vaccine dose were less likely to have more than five symptoms in the first week of illness or present to hospital, and were more likely to be completely asymptomatic, especially if they were 60 years or older.
For the latest recommendations, check out the CDC webpage on Post-COVID-19 Syndrome and Evaluating and Caring for Patients with Post-COVID conditions
Myocarditis
For the latest recommendations, check out the CDC webpage on myocarditis and COVID-19 vaccines
COVID-19 Speakers’ Bureau
Anyone can request a free presentation for a group interested in learning more about the COVID-19 vaccines available in Alaska.
Aside from COVID-19
Respiratory syncytial virus (RSV) activity is increasing; Alaska now meets criteria for an interseasonal RSV period
State of Alaska Section of Epidemiology released a new bulletin detailing Palivizumab Prophylaxis Guidance for RSV. Palivizumab (Synagis®) is a monoclonal antibody that reduces the risk of RSV hospitalization in certain high-risk children. RSV activity is typically seasonal with peak activity in February. RSV activity was very low during the 2020-2021 season and this is thought to be due to masking and social distancing instituted for Covid mitigation. RSV activity in Alaska began again in June 2021 and has increased to the level of an interseasonal RSV period. Alaska’s Statewide RSV Workgroup recommends initiation of interseasonal palivizumab starting September 3, 2021.
CDC and ACIP release recommendations for seasonal Influenza vaccination
The 2021-2022 influenza season is expected to arrive late fall through early spring. Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications. All seasonal influenza vaccine expected to be available this season will be quadrivalent containing hemagglutinin (HA) derived from one influenza A(H1N1)pdm09 virus, one influenza A(H3N2) virus, one influenza B/Victoria lineage virus, and one influenza B/Yamagata lineage virus.
Influenza vaccine may be administered at the same time as COVID-19 vaccine.
Detailed recommendations for influenza vaccination for persons currently infected with COVID-19 are available from CDC.
Upcoming Events/Conferences/Presentations
Alaska Maternal Child Health and Immunization Conference is accepting abstracts
The MCH&I Conference, hosted by Alaska Native Tribal Health Consortium’s Alaska Native Epidemiology Center and the Alaska Dept. of Health & Social Services, Division of Public Health, Section of Women’s, Children’s, and Family Health, is accepting abstracts until Friday, September 17, 2021. There is still time to submit your abstracts by clicking the link - https://www.surveymonkey.com/r/MCHIAbstracts.
Application deadline for Northwest Public Health & Primary Care Leadership Institute approaching on October 1, 2021
Applications for the 2022 Northwest Public Health & Primary Care Leadership Institute are due October 1, 2021 and some partial scholarship funds are available. The Leadership Institute is an offering from the Northwest Center for Public Health Practice and the Northwest Regional Primary Care Association. The program builds on the long-standing training programs of our collaborating organizations and is designed to help mid-career public health and primary care professionals become the next generation of leaders in their fields. The 9-month program runs from January - September 2022, and will develop collaborative, adaptable leaders who can work effectively within and across fields to improve community health.
ANTHC Tribal Health Webinar Series
The ANTHC Tribal Health Webinar series occurs on Friday from 12-1pm on Zoom and is open to the public. Here is the upcoming schedule for the fall and the Zoom link.
08/27: Grace Peterson: Yupi'k People
09/03: Emily Hogeland, MD. ANMC Neonatal Fever Guideline
09/10: Carrie Edmonson, MSN, MPH: Influenza in Alaska
09/17: Joseph Park, DO. Cardiology topic TBD.
09/24: Jason Capo, MD and Ben Westley, MD: ANMC Septic Arthritis Guideline
10/01: Michelle Rothoff, MD: TB in Alaska 101
10/08: Rodrick Smith, MD: Diagnosis and Management of Childhood Seizures
11/05: Rosalyn Singleton, MD: Respiratory/RSV/COVID Hospitalization trends and future interventions.
11/15: Mary Owen, MD: Tlingit People
Join Zoom Meeting
https://anthc.zoom.us/j/98667611681
Meeting ID: 986 6761 1681
One tap mobile
+16699006833,,98667611681#
CDC Clinical Support: There is a Clinician On-Call Center, a 24-hour hotline with trained CDC clinicians standing by to answer COVID-19 questions. Call 1-800-CDC-INFO (800-232-4636) and ask for the Clinician On-Call Center.
All Alaskans and people who work or live in Alaska who are aged 12 years and older are eligible for vaccination against COVID-19. Appointments can be made at covidvax.alaska.gov.
The most up-to-date, evidence based COVID-19 treatment guidelines can be found at:
IDSA Guidelines on the Treatment and Management of Patient with COVID-19
NIH COVID-19 Treatment Guidelines
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