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The COVID wrap: lessons from NSW, reinfection questions, Twitter communications, and other research

In the latest edition of the COVID wrap, public health researcher Alison Barrett reports on some recent research findings and useful resources.


Suppressing the epidemic in New South Wales

McAnulty, JM, New England Journal of Medicine (NEJM), 8 May 2020

The authors describe the response to COVID-19 in NSW, where, as of 3 May, there was a decrease in new daily diagnosed cases.

At the pandemic’s peak in NSW on 27 March, there were 212 confirmed new COVID-19 cases that day; this had dropped to one confirmed case per day by 3 May.

In response to the novel coronavirus pandemic, the NSW Government implemented a Public Health Emergency Operations Centre on 21 January, whose job was communications, identifying cases, tracing contacts and controlling outbreaks.

Local health districts around the state established COVID-19 testing clinics and coordinated personal protective equipment supplies.

From the end of February through March, most of Australia’s confirmed cases were from travellers returning from overseas. In response, from 15 March, foreign travellers were not permitted to arrive into Australia, and all Australian residents returning from overseas had to comply with a 14-day quarantine.

Physical distancing measures were implemented, including people working and studying from home where possible, closure of restaurants and banning of large gatherings.

The authors suggest the likely reasons for NSW and Australia being able to control COVID-19 include the closing of borders, consistent nation-wide policies, regular communication and identification and isolation of confirmed cases. The authors state that the public has largely been compliant with physical distancing guidelines.

The authors conclude by saying:

without high rates of population immunity, New South Wales remains susceptible to COVID-19.

We might be winning the battle, but the social and economic costs are high.

The question now is whether robust identification of new cases and contact tracing can limit transmission sufficiently to permit relaxation of some social measures before a vaccine is available.”

Given the current move to reduce restrictions across Australia, this is a timely concern.


 Re-infection with SARS-CoV-2

Cuthbertson, A, Australian Academy of Science, 19 April 2020

A rapid review published by the Australian Academy of Science has found there is limited evidence to confirm that reinfection with SARS-CoV-2 is possible; and that there may be other potential reasons for what appears to be a reinfected patient.

Over the course of the past few months, there have been anecdotal reports (here, here and here) that some individuals have been reinfected with SARS-CoV-2.

The authors suggest a few possibilities for why a patient who tested positive and recovered from the virus (indicated by one or more negative tests), may go on to test positive again at a later stage:

  • The negative tests to indicate the patient had recovered were incorrect or they had low sensitivity, and the patient may have been infected for the entire period.
  • The patient had recovered and the subsequent positive test is detecting genetic remnants of dead virus.
  • The novel coronavirus may be capable of staying dormant in tissues that are not routinely sampled, before reactivating.
  • The person has actually been reinfected.

The authors advise that reinfection may be possible if 1) antibodies decline after a period time, meaning that the patient would no longer have immunity, but it is too soon to tell if that occurs with SARS-CoV-2; and/or 2) if the virus mutates, it may be possible to be infected by the new mutation of the virus.

Due to the nature of available research on COVID-19 (produced in short time-frames, not yet peer-reviewed, variable testing practices), the evidence for reinfection is not able to be confirmed. More long-term, rigorous studies are required to determine if reinfection from SARS-CoV-2 is possible.

However, while there is limited evidence about reinfection with SARS-CoV-2, it is important not to discount it as a possibility as it may lead to additional outbreaks of the virus.


Cardiovascular disease, drug therapy and mortality in COVID-19

Mehra, MR, New England Journal of Medicine (NEJM), 1 May 2020

In an observational study investigating the association between cardiovascular disease (CVD) and COVID-19 outcomes, researchers found that COVID-19 patients with an underlying cardiovascular condition, such as hyperlipidemia, had a greater risk of death from the novel coronavirus.

These findings, based on hospital records from an international registry of 169 hospitals in Asia, Europe and North America, support results of other smaller studies conducted in China (here and here).

From the study population of 8,910 COVID-19 patients, the patients that died were more likely to be older, male and have a greater prevalence of coronary artery disease, hyperlipidemia and cardiac arrhythmias than those patients who survived. Patients who died were also more likely to have a history of smoking, chronic obstructive pulmonary disease and diabetes.

The researchers also investigated the association between CVD medications (for example, ACE inhibitors and angiotensin-receptor blockers or ARBs) and mortality in COVID-19 patients, as concerns have arisen (here and here) about a potential harmful effect of these medications on patients with COVID-19.

The study found that ACE inhibitors and statins were more commonly used by patients who survived than those who died. No association was found between ARBs and mortality in COVID-19 patients.

While Mehra and colleagues found that the use of ACE inhibitors and statins was linked to better survival outcomes in COVID-19 patients, they highlight that the results of the study should be viewed with caution. They were unable to account for confounding factors; nor determine a cause-and-effect relationship between medication and survival.

In summary, the findings of this study support results from earlier studies indicating a greater risk of death from COVID-19 if a patient has a pre-existing cardiovascular condition. The study did not find a harmful association between ACE inhibitors or ARBs and COVID-19 mortality.


Going viral: how to boost the spread of coronavirus science on social media

Yammine, S, Nature Career Column, 5 May 2020

In early April, Twitter reported that there was a COVID-19-related tweet being shared every 45 milliseconds and that the second most used hashtag of 2020 was #coronavirus.

A study published by the Journal of Medical Internet Research on 21 April, found that the most commonly tweeted topics about COVID-19 were about the origins and source of the novel coronavirus, impact of COVID-19 on people and communities and the methods for decreasing the spread of COVID-19.

These conversations on social media are important and, to avoid misinformation being spread, scientists need to continue to be involved in these conversations. They also need to ensure that this vital information is communicated well.

Dr Samantha Yammine, a science communicator (@SamanthaZY), recommends some advice for sharing information on social media:

  • Amplify others’ tweets first – this is especially important if you don’t have time or skills to create new content. Share and retweet content by trustworthy and credible sources.
  • Avoid ‘hot takes’ – think before you tweet – ensure the information you’re sharing is clear to a general audience and not likely to cause more confusion. Advocacy is important, but if it’s not likely to change public-health policy, then Yammine suggests leaving it for another time.
  • Tailor content to your target audience – for example, if you want to engage young people in physical distancing messages, identify what platforms they are using and what type of content they find most engaging.
  • Avoid clickbait – start with a hook to invite readers to read in more detail. Hooks framed as questions work well, as do pictures.
  • Use hashtags on Instagram and TikTok.
  • When busting myths, do so compassionately and don’t be dismissive. Use it as an opportunity to start developing good relationships.
  • Scientists are people too – be relatable and your authentic self.

Yammine concludes by saying that:

No public health research is complete until the key findings are effectively communicated and, ideally, implemented.

Although the scale of online platforms adds challenges to this task, it can be leveraged to share conversations about the life-saving science we need most.”


WHO Director-General: on easing restrictions

World Health Organization, 11 May 2020

In his latest briefing to media on COVID-19, Dr Tedros discussed the easing of public health restrictions that have been in place in many countries around the world in a bid to slow the spread of COVID-19.

Tedros says while the strict measures were necessary to build capabilities for testing, contact tracing, isolating COVID-19 cases, and ensuring health systems weren’t overburdened, they have placed a great impact on many people’s lives.

It is important to ensure that measures can be implemented promptly if outbreaks occur once restrictions have been eased. He suggests that each country should ask themselves the following three questions to help determine whether restrictions can be eased:

  • Is the epidemic under control?
  • Does the healthcare system have the ability to cope with outbreaks that may arise after restrictions eased?
  • Is the public health surveillance system able to detect, manage and identify further cases?

Even with three positive answers, Tedros says the process of easing restrictions is complex.

In countries that have recently lifted their restrictions, South Korea, China and Germany, clusters of cases have been identified, but then responded to appropriately with good systems in place.

Until a vaccine is available, public health measures must remain in place as countries make plans to ease restrictions.

Tedros also discussed some key factors for local government to consider when making plans to reopen schools:

  1. a clear understanding about current COVID-19 transmission and severity of the virus in children is needed;
  2. where the school is located (is it in an area where there are a lot of cases?); and
  3. does the school have the ability to maintain COVID-19 prevention and control measures?

With regards to reopening work places safely, Tedros recommends that all workplaces conduct a risk assessment on the potential exposure to COVID-19, and implement prevention measures as part of their business plan.

A report by WHO and UNAIDS highlighted that steps need to be taken imminently to minimise interruption to supply of antiretroviral drugs for HIV treatment during the COVID-19 pandemic.

There is a great risk that disruption to this medication will result in many avoidable deaths from AIDS-related conditions in Africa this year.

Tedros concluded his briefing by reiterating that “only together can we get through this pandemic. In national unity and global solidarity.”

All previous media briefings by Tedros can be viewed here.


Other resources

Briefing Note: Impacts of COVID-19 on people living with NCDs

NCD Alliance, April 2020

NCD Alliance has published a briefing note for policy makers about the impacts of COVID-19 on people living with non-communicable diseases.

Key messages in the document:

  • People living with non-communicable diseases are at a higher risk of severe outcomes and death from COVID-19
  • People who are immunocompromised (for example, due to cancer, diabetes) are at a higher risk of complications from COVID-19
  • Evidence suggests that COVID-19 and its treatments may have long-lasting or life-threatening impacts
  • COVID-19 is disrupting essential health services required for people living with NCDs

The full document can be found here.

Strengthening preparedness for COVID-19 in cities and urban settings

World Health Organization, 28 April 2020

The World Health Organization has prepared a document outlining recommendations for cities and urban centres to prepare for recovery from COVID-19, and future emergencies.

Below are some of their recommendations. The document can be downloaded here.

  • Planning and response should be across multiple sectors, including health, education, transport, local government, and financial.
  • Coordination is needed across all levels of government (local, state, national).
  • Existing hazards that could become a health emergency at the same time as managing COVID-19 response should be identified in risk assessments.
  • Vulnerable populations should be identified and protected equitably.
  • Provision of essential services (for example, drug and alcohol support, housing, sanitation, emergency services) should continue.
  • Consideration should be given to maintaining mental health and wellbeing.

The Agency for Clinical Innovation provides rapid (not peer-reviewed) reviews of current evidence related to COVID-19.

Australian Partnership for Preparedness Research on Infectious Disease Emergencies (APPRISE): a compilation of COVID-19 updates and publications.


Alison Barrett is a Masters by Research candidate and research assistant at University of South Australia, with interests in public health, rural health and health inequities. Follow on Twitter: @AlisonSBarrett. Croakey thanks her for providing this column as a probono service to our readers.

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