Today we begin an occasional series bringing you summaries of public health and scientific publications and developments. We are grateful to Alison Barrett for her effort to monitor the literature and compile them.
Severe outcomes among patients with coronavirus disease 2019 (COVID-19) — United States, February 12–March 16, 2020,
Published 18 March by US Centers for Disease Control (CDC): https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm?s_cid=mm6912e2_w
The CDC summarised COVID-19 patient data collected between 12 February and 16 March 2020. To that point, there had been 4,226 COVID-19 cases reported to the CDC.
The key takeaway from this data is that those at highest risk from fatality due COVID-19 are aged 65 or older; 31% of the COVID-19 cases and 80% of deaths in the US were among that group. A similar situation was found in China, where 80% of deaths occurred among adults 60 years of age or older.
While COVID-19 is most common in older adults, cases have been reported in all ages. In the US, 18% of reported cases were aged 55-64 years, 18% were 45-54 years, 29% were 20-44 years and 5% were 19 or under.
Of the 12% of COVID-19 patients that were known to have been hospitalised, those aged 65-84 had the highest incidence of hospitalisations (36% of those hospitalised) and admissions to intensive care units (46% of those admitted to ICU). The hospitalisation rate for those 19 or under was less than 1%, with no ICU admissions or deaths in that age group.
The data at this point is limited. CDC was not able to account for serious underlying health conditions in this cohort; and age and other variables (age, hospitalisation, ICU admissions, death outcome) were not known for 9-53% of total reported cases to the CDC.
Another limitation is that initially testing focussed on those with a travel history or with more severe symptoms. It is possible that the data overestimates the prevalence of severe cases.
Ongoing follow up of the testing data is required to capture outcomes on currently active and future cases.
SARS-CoV-2 infection in children
Published 18 March, 2020, as letter to the editor of the New England Journal of Medicine: https://www.nejm.org/doi/pdf/10.1056/NEJMc2005073?articleTools=true
Doctors at Wuhan Children’s Hospital, China, reported the range and characteristics of symptoms found in children with COVID-19.
Between 28 January and 26 February 2020, the hospital assessed and tested 1,391 symptomatic and asymptomatic children under the age of 16 years suspected of COVID-19 or who had been in contact with a confirmed case. Of those tested, 171 (12.3%) confirmed positive to SARS-CoV-2; the median age was 6.7 years and 60.8% were male.
Common symptoms in the diagnosed children were cough (in 48.5% of cases), red throat (46.2%) and fever (41.5%). There were no symptoms in 15.8% of cases. More than three-quarters (76.6%) of diagnosed children had been exposed to a family member with COVID-19.
Three of the diagnosed children, who all had coexisting conditions, required mechanical ventilation and were placed in intensive care. The report does not advise the medical outcome of these children.
As of 8 March 2020, one child had died with intussusception and multiorgan failure; 149 children had been discharged from hospital and 21 remained in stable condition. Most of the infected children had a mild illness only.
Public health responses to COVID-19 outbreaks on cruise ships — Worldwide, February–March 2020
Outbreaks of COVID-19 have been confirmed on multiple cruise ships during the infectious pandemic. In February and March 2020, more than 800 passengers or crew members have confirmed positive to the SARS-CoV-2 infection on a Diamond Princess voyage and two Grand Princess voyages. Ten deaths have been reported as a result of the infection on these three voyages.
The US Centres for Disease Control and Prevention (CDC) described some of the public health measures effected in response to the outbreak on the cruise ships. After a confirmed case of COVID-19 on the Diamond Princess was reported to officials in Japan, the ship was quarantined in Yokohama port with everyone on board; communication about social distancing and symptoms to monitor were provided to all passengers and staff; and those who tested positive were removed from the ship and hospitalised. They also conducted a stepped disembarkation where they prioritised the testing of older adults, those with underlying medical conditions and no access from their cabin to outdoors. Passengers who had negative test results, no symptoms or close contact with a confirmed case were required to stay on board the ship for a 14-day quarantine. Overall, 712 (19.2%) of the 3,711 Diamond Princess passengers and crew tested positive; 46.5% of these were asymptomatic at the time they were tested. Thirty-seven passengers required intensive care and nine deaths have been reported to date. After the Diamond Princess was vacated, and before it disinfected, the National Institute of Infectious Diseases in Japan identified SARS-CoV-2 RNA on surfaces in cabins of infected passengers, up to 17 days after the cabins had been vacated.
On board the Grand Princess, the CDC notified the ship of positive results of SARS-CoV-2 in two passengers who had left the ship on an earlier voyage: they stopped all group activities; a team was sent to the ship by helicopter to test symptomatic passengers; and other passengers were asked to self-isolate in their cabins. After the vessel docked in Oakland, California, passengers were taken to a land-based quarantine site where they isolated for 14 days, unless they required hospitalisation. Foreign passengers were repatriated where possible and, where not, they remained on board the ship after it had been disinfected. Seventy-eight positive results have been reported from the Grand Princess; of which one passenger has died.
The public health response to the outbreak of COVID19 on these cruise ships was a collaborative effort between multiple stakeholders with the aim of containing the infection on board and preventing further transmission among the community after disembarkation.
In contrast to the described public health measures onboard the Princess cruise ships in Japan and US, on 19 March 2020, Ruby Princess docked in Sydney Harbour, where 2,647 passengers disembarked and were advised to self-isolate for 14 days. While three passengers had been tested prior to disembarkation, at the time of docking, NSW Health advised there had been no cases of COVID-19 identified onboard. However, since then, 133 passengers have tested positive; one of the confirmed cases on board, a female passenger, was reported to have died on 24 March 2020.
COVID-19 and smoking: A systematic review of the evidence
Published by Tobacco Induced Diseases
Smoking is assumed to be related to worse outcomes in people with COVID-19, however limited data exists. On 17 March 2020, the authors searched PubMed and ScienceDirect for eligible studies and after full-text screening, they included five studies in the review. All five were conducted in China – four in Wuhan province and one across multiple regions in China – between December 2019 and January 2020.
Similar to research by Park, Jung & Kim (2018), who found smokers had higher mortality during the MERS-CoV outbreak, this review indicates that smoking is a risk factor for worse progression and outcomes of COVID-19. In the study with the largest population, in the group of patients with severe symptoms, 16.9% were current smokers compared to those with non-severe symptoms, of whom 11.8% were current smokers.
There are limitations to this review. It is unclear, but unlikely given the quick turnaround of the review, whether the reviewers appraised the quality of the five studies. Four of the included studies had a small sample size and were derived from a single centre. The results were not adjusted for other potential risk factors that may impact COVID-19 outcome.
At the epicenter of the COVID-19 pandemic and humanitarian crises in Italy: Changing perspectives on preparation and mitigation
Published 21 March 2020 by New England Journal of Medicine: Catalyst: https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0080
Staff working in a Bergamo hospital, in one of Italy’s most affected regions, have provided an insight into the situation they face and their recommendations for dealing with future pandemics. At the time of publication, there had been 4,305 cases of COVID-19 reported in Bergamo, more than any other region in Italy. It is a wealthy and densely populated region.
They report that 30% of their hospital beds are occupied by COVID-19 patients and 70% of their ICU beds are saved for COVID-19 patients who have a good chance of survival. “Older patients are not being resuscitated and die alone without appropriate palliative care,” they report. Most hospitals in the nearby regions are similarly overcrowded and struggling to maintain regular health care services. With hospitals being as overcrowded as they are, they are probably enabling uninfected patients to become infected with COVID-19.
The key point they make is that: “Western health care systems have been built around the concept of patient-centered care, but an epidemic requires a change of perspective toward a concept of community-centered care,” with public health and epidemic experts required at the forefront to help make decisions that will improve the situation.
Some of the public health measures the authors recommend are the implementation of outreach services to lighten the load on hospitals, dedicated virus-free areas in hospitals, and prioritisation of protective equipment for medical staff. They also reiterate that social distancing is required to reduce the rate of COVID-19 infections, and that epidemiologists, social workers, psychologists and humanitarians with experience in local engagement working together would all help contain the outbreak.
In summary, to contain the current coronavirus outbreak and plan for future pandemics, a coordinated effort with a shift away from medicalised, person-centred care is required.
WHO Director-General’s opening remarks at the media briefing on COVID-19 – 20 March 2020
On 20 March 2020, the World Health Organisation’s (WHO) director-general, Dr Tedros Adhanom Ghebreyesus, spoke to the media. At that time, there had been 210,000 COVID-19 cases worldwide reported to WHO and 9,000 deaths.
He said on 19 March there had been no new reported cases in Wuhan, China, for the first time since the outbreak started, providing hope that “even the most severe situation can be turned around.”
While older people are more susceptible to contracting COVID-19 and with more severe outcomes, young people are not immune and are still susceptible to getting infected and requiring hospitalisation. This can be seen in data recently released by the CDC.
He relayed an important message to young people: “You are not invincible. The virus could put you in hospital for weeks, or even kill you. Even if you don’t get sick, the choices you make about where you go could be the difference between life and death for someone else.”
Dr Tedros has great concern for vulnerable populations and countries with a weaker health system, advising that WHO is working to support all countries. He has other concerns about limited supplies of personal protective equipment for health workers and testing kits. He noted that China and Kuwait have provided help in the past week with the production of more equipment and funding to WHO to help support their efforts.
It is in this time, he says that “solidarity is the key to defeating COVID-19- solidarity between countries, but also between age groups.”
He provided some advice on how to look after your physical and mental health: eat healthy and nutritious foods, limit intake of alcohol and sugary drinks, don’t smoke, exercise (if you can’t leave the house, try dancing to music, doing yoga, finding an online exercise group), and if you’re working from home, have a 3-minute break every 30 minutes.
WHO have also collaborated with WhatsApp and Facebook to release a health alert messaging service that provides the latest news and information on COVID-19. To access it, send the word “hi” to the following number on WhatsApp: +41 798 931 892.
Dr Tedros ended his briefing with this statement:
“COVID-19 is taking so much from us. But it’s also giving us something special – the opportunity to come together as one humanity – to work together, to learn together, to grow together.”
WHO Director-General’s opening remarks at media briefing on COVID-19 – 23 March 2020
Dr Tedros acknowledged FIFA’s generous contribution of US$10 million to the World Health Organisation’s (WHO) COVID-19 Solidarity Response Fund; and the new campaign between FIFA and WHO to “pass the message to kick out coronavirus,” highlighting that football has the opportunity to reach many people, particularly young people.
The social media company TikTok has also donated US$10 million to the fund and will provide support to reach young people with health information about COVID-19.
As of 23 March, more than 300,000 cases of COVID-19 had been reported to WHO, with the number of infections growing rapidly. “It took 67 days from the first reported case to reach the first 100,000 cases, 11 days for the second 100,000 cases and just 4 days for the third 100,000 cases,” Dr Tedros said.
To slow down the pandemic, Dr Tedros asked people to stay at home and put in place physical distancing measures; however, these are defensive measures. To attack COVID-19, he says every suspected case must be tested and that every confirmed case must be isolated, cared for and all close contacts must be traced and quarantined, acknowledging that some countries are finding it a challenge to put in place these measures.
He thanked the countries that have sent emergency medical teams to other countries that need help in caring for patients and training health workers. Many health workers around the world are reported to be infected and it is a priority that they must have appropriate protective equipment (PPE). Dr Tedros will address governments and heads of state from G20 countries this week to discuss the issue of limited supplies required to make the PPE required.
He urged leaders of G20, “who have more than 80% of global GDP,” to act in solidarity and “ensure equity of distribution” of products and materials at this time.
Dr Tedros was encouraged by the research being done to combat COVID-19, but emphasised the research must be robust and high-quality for it to have impact. As such, they have launched the SOLIDARITY trial to facilitate gathering the quality evidence.
Alison Barrett is a Masters by Research candidate and research assistant at University of South Australia, with interests in public, rural health and health inequities
For a compilation of research on COVID-19, see https://ucsf.app.box.com/s/2laxq0v00zg2ope9jppsqtnv1mtxd52z