COVID-19: Infection prevention and control
May 29
SARS-CoV-2 transmission in offices and poorly ventilated spaces
New/updated CDC COVID-19 employer guidance for office settings (CDC, May 27)
includes suggestions of ways to increase the distance between employees and to disinfect workspaces. Notably, the CDC recommends that employees wear a cloth face covering in all areas of the business. This guidance could be useful for Ohio office-based employers who are making decisions regarding employees’ primary places of work. The guidance also includes links to other sources of information on suggested ventilation and water safety protocols.
A commentary on the spread of COVID-19 through droplets (The Lancet Respiratory Medicine, May 27) studied the rate at which large and small droplets from speaking, breathing and coughing fall to the ground after being expelled. Large droplets tended to fall to the ground quickly and do not travel far before doing so. Small droplets tended to linger in the air for about 9 minutes before reaching the ground. Furthermore, they examine how types of ventilation affect the rate at which potentially viral-laden droplets can be removed from a room. The best ventilation reduced the number of droplets in the room by half after 30 seconds, the second-best reduced droplets by half in one to four minutes, and no ventilation took five minutes to reduce droplets by half.
These results could be useful when designing COVID-19 response policies for poorly ventilated spaces, like public transport and nursing homes, which have been reported as sites of viral transmission despite preventive physical distancing. The authors recommend that public health officials advocate for the avoidance of poorly ventilated spaces and improved ventilation to reduce potentially infectious aerosols.
Effectiveness of stay-at-home orders
A study of state-level stay-at-home orders on COVID-19 (American Journal of Infection Control, May 24) found that infection rates dropped after state orders were put in place. Infection rates were 0.113/day pre-order and 0.047/day post-order. The results were consistent across states and support the usefulness of stay-at-home orders in reducing COVID-19 infection rates. Before the stay-at-home order, Ohio’s infection rate was 0.15 per day. After the order was put in place, the infection rate dropped to 0.053 per day.
Municipal sewage testing as a COVID-19 outbreak indicator
A study on the effectiveness of testing waste water to determine prevalence of COVID-19 (Yale University and Connecticut Agricultural Experimental Station [published pre-print by MedRxIV], May 22) found that sampling sewage is a potential way for states to detect and study potential trends in cases of COVID-19 earlier than currently possible from indicators such as local hospital admissions and compiled COVID-19 testing data. The study examined SARS-CoV-2 RNA concentration in the primary sewage sludge of a northeastern United States metropolitan area (New Haven, Connecticut) amid the Spring 2020 outbreak of COVID-19. All environmental samples collected and included in the study contained SARS-CoV-2 RNA and showed a high correlation with the COVID-19 epidemiological curve as well as with local hospital admissions. The concentration of SARS-CoV-2 RNA in the primary sewage sludge samples was subsequently identified as a seven-day leading indicator ahead of COVID-19 testing data and predated local hospital admissions data by three days.
May 27
SARS-CoV-2 screening in long-term care settings
A study of COVID-19 spread in assisted and independent living (JAMA, May 21) found that early universal surveillance to identify asymptomatic infections, coupled with prevention strategies, can reduce the likelihood of a widespread outbreak. The study involved universal testing of 80 residents in assisted living and independent living communities twice, with the second screening seven days after the first. A symptom questionnaire was also completed by residents and staff. Staff were tested once. SARS-CoV-2 was detected in three residents (3.8%), with none of them feeling ill and one reporting that he had recently had a cough and loose stool. Two of 62 staff (3.2%) tested positive for the virus, both having symptoms. One new resident infection was found during the second round of viral testing. This resident was not experiencing symptoms. All four residents who tested positive remained asymptomatic throughout the next 14 days, highlighting the challenge of controlling infection spread using symptom screening alone. Social isolation and infection prevention protocols were implemented at the site throughout the time of the study. A widespread outbreak was avoided. Two residents were hospitalized with COVID-19 prior to the study, with the study beginning rapidly after these hospitalizations.
A study of SARS-CoV-2 infection at a skilled nursing facility for veterans (CDC MMWR, May 22) found that universal and repeated testing of both residents and staff, along with isolation and cohorting of residents who test positive for COVID-19, were effective strategies for preventing infection at this skilled nursing facility. All 99 residents at the facility were tested and a total of 19 cases were diagnosed (19.2%). Fourteen of the 19 cases were asymptomatic and eight of the 14 later developed symptoms. Of 136 staff, eight were found to have COVID-19 with half of those being asymptomatic. Testing of all residents was repeated weekly until all residents had negative test results. One resident died with COVID-19. “Swift isolation and cohorting of residents with COVID-19 reduced further transmission within the SNF; residents who had positive test results were quickly transferred out of the SNF, either to the acute care hospital or directly to a separate COVID-19 recovery unit.”
Superspreading during mass gatherings
A study describing a COVID-19 outbreak in Jordan that began after a wedding (CDC Emerging Infectious Diseases, May 20) demonstrates the high communicability of COVID-19 and the significant risk for SARS-CoV-2 virus transmission during mass gatherings. Of 350 wedding attendees, 76 developed COVID-19, an attack rate of 22%. Authors noted a high rate (47.4%) of asymptomatic carriers among those infected. Before the outbreak from this wedding, only one case, which was imported, had been reported in Jordan in early March. By April 10, the number of confirmed cases from the wedding constituted 24% of all COVID-19 cases in Jordan.
Risk stratification for workers
A report on standards for returning to work (NEJM, May 26) proposes a framework to help clinicians counsel patients about continuing to work in the midst of the pandemic that is based on their occupational risk of contracting SARS-CoV-2 and their risk of death if they are infected. This framework is displayed in a matrix that stratifies individual risk based on occupational and personal factors. Persons with high occupational risk of contracting COVID-19 and/or high personal risk of death from COVID-19 should consider stopping work and discuss risk with their clinician.
May 11
Pandemic response in correctional and detention facilities
A study of COVID-19 in the Louisiana prison system (MMWR, May 8) found that physical, logistical and security constraints inherent to correctional facilities make it difficult to fully implement public health recommendations related to the pandemic. The reported inability of some facilities to individually quarantine close contacts of incarcerated or detained persons with COVID-19 could result in spread among persons within the quarantine units. A COVID-19 Management Assessment and Response (CMAR) tool could be used to assess COVID-19 management practices and guide strategies to address gaps. Response to COVID-19 in correctional and detention facilities should account for the inherent limitations these facilities face in acting upon public health guidance.
A World Health Organization document providing guidance to assist correctional and detention facilities in developing a response to the COVID-19 (WHO, March 15) outbreak highlights that people in prisons and other places of detention are likely to be more vulnerable to the COVID-19 outbreak than the general population because of the confined conditions in which they live together for prolonged periods of time. Moreover, experience shows that prisons, jails and similar settings where people are gathered in close proximity may act as a source of infection, amplification and spread of infectious diseases within and beyond prisons. Controlling the spread of COVID-19 infection in prisons and other places of detention is essential to protecting the health of all those who live and work in them and those who visit them and protecting the outside community. The WHO also created a companion checklist for use by policymakers and prison administrators to evaluate their level of preparedness to prevent and control COVID-19 in prisons and other places of detention.
May 8
Pediatric condition potentially associated with SARS-CoV-2
A study of a cluster of eight children with hyperinflammatory shock (The Lancet, May 7) suggests that a new phenomenon affecting previously asymptomatic children with SARS-CoV-2 infection manifesting as a hyperinflammatory syndrome with multiorgan involvement similar to Kawasaki disease shock syndrome. The multifaceted nature of the disease course underlines the need for multispecialty input (intensive care, cardiology, infectious diseases, immunology, and rheumatology). Clinical presentations were similar, with unrelenting fever, variable rash, conjunctivitis, peripheral edema, and generalized extremity pain with significant gastrointestinal symptoms. All children initially tested negative for SARS-CoV-2 on broncho-alveolar lavage or nasopharyngeal aspirates. Since discharge, two of the children tested positive for SARS-CoV-2.
An alert from the New York City Health department (NYC Health, May 4) notified pediatric providers of 15 cases of a pediatric multi-system inflammatory syndrome similar to cases reported in the U.K. Among the 15 cases identified in New York, 4 tested positive for SARS-CoV-2 by PCR testing, 6 tested negative by PCR and positive by serology and 5 were negative. The alert provides instructions for providers to refer potential cases to appropriate specialists and the NYC Health Department.
May 6
Evidence of presymptomatic and asymptomatic spread
A literature review of the most recent epidemiologic, virologic and modeling evidence (CDC Emerging Infectious Diseases, May 4) found support for possible transmission of SARS-CoV-2, the virus that causes COVID-19, from people who are presymptomatic or asymptomatic. SARS-CoV-2 transmission in the absence of symptoms reinforces the value of measures that prevent the spread of SARS-CoV-2 by infected persons who may not exhibit illness despite being infectious.
Mobility and virus transmission
A modeling study uses death and mobility data from several regions in northern Italy (Imperial College, May 4) found that, in the absence of additional interventions, even a 20% return to pre-lockdown mobility could lead to a resurgence in the number of deaths far greater than experienced in the current wave in several regions. The study estimates the impact on mortality of three post-lockdown scenarios over the next eight weeks: (1) mobility remains the same as during the lockdown, (2) mobility returns to pre-lockdown levels by 20% and (3) mobility returns to pre-lockdown levels by 40%. The mobility data was provided by Google and serves as a proxy for behavior change caused by non-pharmaceutical interventions, including change in visits to locations such as grocery stores, parks, transit stations, retail and workplaces. Because increases in the number of hospitalizations and deaths lag behind increases in transmission intensity, the control of a future potential resurgence in transmission relies on the early identification and isolation of infections and on the timely suppression of local clusters of infection.
A study of cell phone data at various types of businesses (MIT, April 26) found that “banks, general merchandise stores, dentists, grocery stores and colleges should face relatively loose restrictions and gyms, sporting goods stores, liquor stores, tobacco stores and cafes should face relatively tight restrictions.” The study uses Safegraph data from cell phones, as well as measures related to 30 categories of businesses, to inform re-opening policies. The findings can inform re-opening policies and, if necessary, future closure policies.
A study of the spread of COVID-19 using cell phone data (NBER, April 1) found that small businesses should be permitted to re-open first, as these are generally less dense environments. A caveat is that these businesses would have to be as good as larger businesses at public health practices (i.e. wearing masks, no-touch doors). It is important to note that, since the study only looks at mobile tracking data, it does not include what people were doing in these stores (i.e. shopping, working).
May 1
Workplace reopening and safety guidance
A CDC report on factors contributing to the spread of COVID-19 in meatpacking and poultry processing plants (CDC MMWR early release, May 1) includes data on 115 facilities with 130,000 workers in19 states, including Ohio. There have been 4,913 cases confirmed and 20 deaths in meat processing facilities. Lack of physical distancing and cleanliness are cited as contributors to spread, in addition to multigenerational and dense living situations and language barriers in some facilities. Recommendations include improving distancing to the extent possible, engineering approaches (such as not having fans blowing across workers), encouraging cloth masks (if cleaned regularly and with appropriate donning and doffing) and handwashing, disinfecting surfaces and providing paid medical leave for workers who are ill. Training should be provided by culturally competent trainers in the language spoken by workers. Data for Ohio indicated 10 cases in 1 pork plant with 710 workers. No deaths were reported.
A new CDC framework for cleaning and disinfection practices in public spaces, workplaces, schools and homes (CDC, April 28) highlights that reopening public spaces will require careful planning and emphasizes the importance of reducing the risk of exposure to COVID-19 by cleaning and disinfection. The framework states that normal routine cleaning with soap and water will decrease how much of the virus is on surfaces and objects. The authors also state that disinfection using EPA-approved disinfectants against COVID-19 can also help reduce the risk. The EPA has compiled a list of disinfectant products that can be used against COVID-19, available on the EPA website. When EPA-approved disinfectants are not available, alternative disinfectants can be used (e.g. 1/3 cup of bleach added to 1 gallon of water, or 70% alcohol solutions).
Contact tracing and isolation strategies
An epidemiological study of COVID-19 (The Lancet Infectious Diseases, April 27) found that the attack rate of the virus does not differ significantly by age, with on average 7% of close contacts becoming infected, around 80% of these contacts showing symptoms and 3% of infections manifesting severe disease at initial assessment. They also found that contact-based surveillance and isolation in Shenzhen, China reduced the duration an infected individual transmits in the community by 2 days. The household secondary attack rate was 11.2%, and children were as likely to be infected as adults. The observed reproductive number (R) was 0.4, with a mean serial interval of 6.3 days. The authors found that because children were at a similar risk of infection to the general population, they should be considered in analyses of transmission and control. The analysis presents one of the first estimates of the serial interval, secondary household attack rate and dispersion for SARS-CoV-2, the virus that causes COVID-19, based on active surveillance data.
A comparison of institution-based and home-based isolation for COVID-19 (The Lancet, April 29) found that institution-based isolation, modeled after China, reduced contact rates by 75% in the household and by 90% in the community. The authors estimated that home-based isolation, modeled after Europe and the U.S., caused a 50% reduction in contact within the home and a 75% reduction in contact in the community. The authors of the study suggest that policymakers facing overburdened health-care facilities to consider strategies to reduce transmission, such as repurposing hotels or dormitories.
A study of isolation and tracing strategies found that, in most scenarios, highly effective contact tracing and case isolation are enough to control a new outbreak of COVID-19 within 3 months. The probability of control decreases, however, with long delays from symptom onset to isolation, fewer cases ascertained by contact tracing and increasing transmission before symptoms.
April 30
Protective immunity
An article on immunology and COVID-19 (The Lancet, April 27) states that most of the available COVID-19 serology data derive from people who have been hospitalized with severe infection. In this group, around 90% develop antibodies within the first 2 weeks of symptomatic infection. However, a key question concerns antibodies in non-hospitalized individuals who either have milder disease or no symptoms. Anecdotal results from community samples have found that less than 10% of those tested developed specific antibodies. In the absence of larger seroprevalence datasets, it seems likely that natural exposure during this pandemic might, in the short to medium term, not deliver the required level of herd immunity and there will be a substantial need for mass vaccination programs.
April 28
Mitigating the spread of COVID-19 in healthcare settings
A simulation study of the effectiveness personal protective equipment for emergency physicians and nurses (JAMA Research Letter, April 27) found that, despite the use of PPE, fluorescent markers were found on the uncovered skin, hair and shoes of participants after simulations of the emergency department management of patients experiencing respiratory distress. The findings suggest that the current recommendations for personal protective equipment may not fully prevent exposures in emergency department settings. Clothing that covers all skin may further diminish exposure risk.
A study investigated the aerodynamic nature of SARS-CoV-2 (Nature, April 27) found that the concentration of COVID-19 virus in aerosols detected in isolation wards and ventilated patient rooms in two hospitals in Wuhan, China was very low, but it was elevated in patient bathrooms. Levels of airborne SARS-CoV-2 RNA in the majority of public areas was undetectable, except in two areas prone to crowding, possibly due to infected carriers in the crowd. Authors found that some medical staff areas initially had high concentrations of viral RNA, but these levels were reduced to undetectable levels after implementation of rigorous sanitization procedures. To reduce the concentration of SARS-CoV-2 aerosol in medical staff areas, hospitals can implement more rigorous and thorough sanitization measures, including more frequent spraying of chlorinated disinfectant on the floor of patient areas, spraying alcohol disinfectant all over the protective apparel before taking off and prolonged operation time of indoor air purifiers. Results also indicate that room ventilation, open space and proper use and disinfection of bathrooms can effectively limit the concentration of SARS-CoV-2 RNA in aerosols.
April 27
Workplace infections
An epidemiological study of a COVID-19 outbreak in a call center in South Korea (CDC, Emerging Infectious Diseases, April 23) found that of 1,143 persons who were tested for COVID-19, a total of 97 had confirmed cases. Of these, 94 were working on the same floor of a call center with 216 employees, translating to an attack rate of 43.5%. The household secondary attack rate among symptomatic case-patients was 16.2%. This outbreak shows that SARS-CoV-2, the virus that causes COVID-19, can be exceptionally contagious in crowded office settings such as a call center. The magnitude of the outbreak illustrates how a high-density work environment can become a high-risk site for the spread of COVID-19 and potentially a source of further transmission. In this case, extensive contact tracing, testing all contacts and early quarantine blocked further transmission and may be an effective approach for containing rapid outbreaks in crowded work settings.
April 20
Aerosol transmission of COVID-19 and the role of face masks
New analysis provides information on how COVID-19 is transmitted and the role masks can play in reducing spread of the disease. An experiment on COVID-19 transmission (New England Journal of Medicine, April 15) and accompanying video use laser light to show that speech generates respiratory droplets and to test the effectiveness of a mouth covering to reduce droplets. The experiment and video illustrate the need for people to wear masks in public to protect others.A letter on the transmission of the COVID-19 virus (New England Journal of Medicine, April 15) explains that talking and breathing generate aerosolized particles in addition to respiratory droplets. Research has shown that aerosolized particles can contain SARS-CoV-2, the virus that causes COVID-19. The author explains that aerosolized particles can be inhaled into the lungs and, therefore, may be a source for transmitting SARS-CoV-2. This letter provides additional explanation of the importance of wearing masks in public.A commentary on “mass masking” (Lancet, April 16) argues that the practice is a low-cost and potentially effective mechanism to reduce the spread of infection and that it should be encouraged and/or required during the next phase of the COVID-19 pandemic. This strategy can be promoted as a matter of protecting others rather than as a strategy to protect oneself.
COVID-19 transmission dynamics in California, Washington
An examination of enrollees in the Kaiser Permanente health plan (MedRxIV, April 16) identified 1,277 hospitalized patients with COVID-19 out of nearly 9.6 million people enrolled in health plans, with hospitalization rates ranging from 10.6 to 14.6 per 100,000. The authors found that 42% of hospitalized patients required intensive care, higher than the 30% reported from China. They also found an average 11-day length of stay, which is similar to China, but higher than that used by some models to project hospital capacity needs. Frequency of hospitalization was higher for people over the age of 80. The effective reproductive number of the virus declined to less than 1 during the time period of the study, indicating that non-pharmaceutical interventions put in place in California and Washington resulted in reduced transmission.
April 16
Intermittent social distancing may be needed long term
A modeling study based on other coronaviruses (Science, April 14) projects that recurrent wintertime outbreaks of SARS-CoV-2, the virus that causes COVID-19, will probably occur after the initial, most severe pandemic wave. The authors conclude that intermittent social distancing could prevent critical care capacity from being exceeded, but that widespread surveillance will be required to time the distancing measures correctly. Periodic social distancing will likely need to continue through 2022 or beyond in order to avoid overwhelming the healthcare system. The findings mean that Ohio policymakers should be prepared to implement intermittent social distancing over the long-term to handle possible seasonal peaks that could strain the critical care system. Effective timing of changes in social distancing should be informed by widespread surveillance, indicating that increased testing capacity (including serological testing) is critical for informing policy decisions. Once data are available, benchmarks could be established to guide timing of increased and decreased social distancing policies.
April 14
COVID-19 virus found on shoes, office equipment of hospital workers
A study of hospital wards in Wuhan, China (CDC, Emerging Infectious Diseases, April 10) found that SARS-CoV-2 (the virus that causes COVID-19) was relatively common on floor swab samples and swab samples from the soles of ICU medical staff shoes. This may be because of gravity, airflow and medical staff foot traffic. The rate of positivity was also relatively high for objects that were frequently touched by medical staff or patients (e.g., computer mice, trashcans, handrails and doorknobs). The authors recommend that staff disinfect shoe soles before walking out of wards with COVID-19 patients, perform hand hygiene practices immediately after patient contact and disinfect used patient masks before discarding. The study found that environmental contamination was greater in the ICU than in the general ward; thus, stricter protective measures should be taken by medical staff working in the ICU.
Plan lays out steps needed before easing social distancing
A new plan for easing social distancing (Johns Hopkins University Bloomberg School of Public Health and the Association of State and Territorial Health Officials, April 10) argues that ending strict social distancing measures will require (1) ready access to rapid diagnostic tests for all symptomatic cases or those with a reasonable suspicion of COVID-19 exposure; (2) widespread serological testing to understand underlying rates of infection and identify those who have developed immunity and could potentially return to work or school without fear of becoming infected; and (3) the ability to trace all contacts of reported cases. The authors estimate that tracing all contacts will require a national public health workforce expansion of at least 100,000 people and a $3.6 billion investment. Although the plan requires federal leadership and funding, much of the responsibility for implementation would fall to state and local entities. To prepare, state and local entities can take steps now, for example, by adapting processes and procedures to accommodate rapid public health workforce expansion and improving data collection and management systems for contact tracing.
April 10
Assessment outlines lessons learned from China’s relaxing of social distancing restrictions
An assessment of COVID-19 in China (Lancet, April 8) found that because herd immunity has not been achieved, relaxing non-pharmaceutical interventions (NPI) such as social distancing, should be done with caution. The authors found that if restrictions are not relaxed gradually, the number of positive cases could begin rising exponentially. As NPIs are relaxed in Ohio and the rest of the United States, transmission rate and case fatality risk will need to be closely monitored. Monitoring these outcomes requires capacity for widespread testing.
Studies shed light on impact of COVID-19 school closures
A review of school closures during the COVID-19 outbreak(Lancet, April 6) shows mixed evidence of effectiveness. According to the authors, widespread school closures that have been implemented in response to the COVID-19 pandemic are based on evidence for influenza outbreaks. Evidence from coronavirus outbreaks, including the COVID-19 outbreak, is limited and mixed. According to the authors, more research is needed. They state that “the evidence to support national closure of schools to combat COVID-19 is very weak and data from influenza outbreaks suggest that school closures could have relatively small effects on a virus with COVID-19’s high transmissibility and apparent low clinical effect on school children.” Furthermore, school closures can have severe social and economic consequences.A commentary on school closures (Lancet, April 7) outlines two mechanisms through which school closures will affect low-income children in the USA and Europe. The authors state that closing schools for a long period of time could have detrimental social and health consequences for children living in poverty, and exacerbate existing inequalities. First, school closures will increase food insecurity, and second, school closures are likely to widen the learning gap between children from families with lower incomes and families with higher incomes.
Tactics outlined for increasing public health capacity to address COVID-19 pandemic
An article (MIT Technology Review, April 8) describing a new task force in San Francisco to support the contact tracing efforts of local health departments offers a blueprint for building similar public health capacity in other areas of the country. The article explores the importance of contact tracing and provides examples of how this work has been done during the COVID-19 outbreak in other countries.Another article(JAMA, April 8) describes another tactic for increasing public health capacity for addressing the pandemic. The authors recommend suspending the first year of medical school for the upcoming academic year and enlisting those students in a national service program for public health to address a possible second wave of COVID-19. The authors suggest that the students could take online training courses in July focused on infectious diseases and outbreak response and then be deployed in state and local health departments to increase capacity in multiple roles, including surveillance and call center staffing.
April 9
Study finds link between air pollution, COVID-19 death rate
A study (Harvard, April 5) investigating the link between air quality and COVID-19 found that long-term exposure to air pollution increases the risk of COVID-19 deaths in the United States. According to the study, a small increase in long-term exposure to fine particulate matter in the air leads to a large increase in the COVID-19 death rate. HPIO’s 2019 Health Value Dashboardshows that Ohio ranks 46 out of the 50 states and D.C. in outdoor air quality (average exposure of the general public to particulate matter of 2.5 microns or less in size) for 2015-2017.
Mitigating COVID-19 spread in correctional facilities
An article (JAMA, April 7) discussing COVID-19 transmission in correctional facilities found that the challenges of minimizing the virus include the inability to physically distance inmates, shared facilities and restricted access to soap and hand sanitizers. Prisoners in any given facility come from a variety of locations, increasing the chance of introducing the virus. Also, a higher than average proportion of incarcerated individuals have underlying illnesses that increase the risk of severe cases of COVID-19. The report contains several recommendations for minimizing spread, including preparing dedicated facilities for mild cases that do not require hospitalization, ensuring incarcerated individuals have access to sufficient soap and hand sanitizer at no charge and releasing those held for nonpayment of fees and fines or inability to post bail and releasing prisoners who are near the end of their sentences for nonviolent crimes. All staff, visitors and contractors should also be screened for symptoms upon entry into facilities.
April 8
Studies examine how long the COVID-19 virus lives
Recent research has shed light on how long the SARS-CoV-2 virus remains active on various surfaces and under various conditions.A study of the SARS-CoV-2 virus (Lancet, April 2) found that heat and standard disinfection methods can reduce how long it lives. The article found that the virus becomes inactive in five minutes at 70° C (158° F). At room temperature, the virus lasts 3 hours on paper, 2 days on wood and cloth, 4 days on glass and money, 7 days on stainless steel and plastic and was still detectible on the exterior of surgical masks after 7 days. Authors also tested standard disinfectants and found that they work. After using disinfectant, no infection could be detected after a 5-minute incubation at room temperature, with the exception of hand soap (which showed undetectable levels of the virus after 15 minutes).A letter published in the New England Journal of Medicine(March 17) stated that SARS-CoV-2 remained viable in aerosols throughout the duration of a recent 3-hour experiment. The longest viability of both viruses was on stainless steel and plastic, with lower viability on copper and cardboard. The virus was detected up to 72 hours after application to stainless steel and plastic. On copper, no viable SARS-CoV-2 was measured after 4 hours, and on cardboard, no viable SARS-CoV-2 was measured after 24 hours. The authors conclude that aerosol and surface transmission of SARS-CoV-2 is plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days; and that hospital spread and super-spreading events are likely.
April 6
Study of 1918 flu pandemic finds that social distancing can help economy in long run
A study of the impact of social distancing(SSRN, March 30) during the 1918 flu pandemic found that cities that implemented non-pharmaceutical interventions, or NPIs, earlier and more aggressively may have seen faster economic growth after the pandemic. The authors found that pandemics reduce economic activity and that NPIs reduce mortality. According to the authors, “NPIs not only lower mortality; they also mitigate the adverse economic consequences of a pandemic.”
April 3
Lessons learned from Seattle and New York
In an audio interview (NEJM, April 1, 2020), editors of the New England Journal of Medicine share lessons learned from New York City and Seattle. They discuss New York as an example of a city with widespread community transmission and Seattle as an example of how infections among vulnerable populations increase demand on the healthcare system. Highlights from the interview include:
- To flatten the curve on hospital demand, focus on reducing the spread of infection in healthcare facilities and other environments with highly vulnerable populations
- Maintain social distancing efforts while working toward faster and more widespread testing and building healthcare capacity
- Policy action may be needed to address healthcare worker shortage
New guidance on masking policies in hospital settings
A perspective article (NEJM, April 1) addresses the potential benefits of universal masking, particularly in hospital facilities, to protect against transmission from workers to patients. However, authors caution against over emphasis on masking as a strategy to reduce the spread of infection. The authors write that hospital systems should ensure that, in addition to masking, fundamental infection-control measures are in place. For example, careful screening of patients for symptoms and isolation of patients with potential COVID-19, strict policies for healthcare workers to report symptoms to their employer and enabling workers to practice social distancing in all work-related settings.
April 2
Presymptomatic transmission and ease of transmission
New research underscores some of the challenges with slowing the spread of COVID-19.A study of COVID-19 cases in Singapore (CDC, April 1) found that people infected with the coronavirus can spread the disease one to three days before they develop symptoms. Given this information, public health officials conducting contact tracing should strongly consider including a period before symptom onset to account for the possibility of presymptomatic transmission. The study also emphasizes the need for social distancing to prevent further spread of the disease.New research (JAMA, March 26) found that coughing and sneezing can propel pathogens as far as 23 to 27 feet through the air. While the study was not specific to COVID-19 cases, the finding means recommendations for social distance separations of 6 feet may underestimate the distance, timescale and persistence over which the COVID-19 virus can travel. For this reason, it is important that health care workers wear appropriate personal protective equipment while caring for patients who may be infected, even if they are farther than 6 feet away. This may also offer support for potential recommendations for all people to wear masks when out in public.
Underlying health conditions and risk for severe COVID-19
A preliminary review of U.S. COVID-19 data(CDC, March 31) found that people with underlying health conditions (i.e., diabetes, chronic lung disease and cardiovascular disease) appear to be at higher risk for severe COVID-19-associated disease than persons without these conditions. As described in the 2019 Health Value Dashboard and the 2019 State Health Assessment, Ohio has relatively high rates of chronic diseases that may increase the severity of COVID-19 complications. Ohio ranks in the bottom quartile, for example, for adult smoking, adult obesity and cardiovascular disease mortality.
April 1
Planning beyond the initial COVID-19 surge
As Ohio braces for a surge in COVID-19 cases in the coming weeks, plans are already underway for what steps will need to be taken once the number of cases begins to decline. Several new studies offer guidance on considerations for deciding when restrictions can safely be lifted.Policymakers, with the help of individual Ohioans, are currently taking steps to reduce infections and expand hospital capacity. A report from the American Enterprise Institute (March 29) outlines specific directions for transitioning away from mitigation strategies that target entire populations to new tools and approaches that target those with infection and prevent further spread of the disease. Specific action steps are discussed across four phases of disease spread and progression: Phase 1 – Slow the Spread; Phase 2 – Reopen, State by State; Phase 3 – Establish protection then lift all restrictions; Phase 4 – Rebuild readiness for the next pandemic. Moving to Phase II requires a state to meet the following criteria: (1) a sustained reduction in cases for at least 14 days; (2) hospitals in the state are safely able to treat all patients requiring hospitalization without resorting to crisis standards of care; (3) the state is able to test all people with COVID-19 symptoms; (4) the state is able to conduct active monitoring of confirmed cases and their contacts.Another factor that policymakers must consider is the possibility of a second wave of outbreak. A modeling study(medRxiv, March 24) predicts that seasonal variation will reduce transmission during the summer months but could lead to an intense resurgence in the autumn, necessitating additional interventions, such as increased critical care capacity. They also found that a single period of social distancing will not be sufficient to prevent overwhelming critical care capacity; intermittent distancing measures may be the only way to avoid exceeding critical care capacity until immunity increases and effective therapeutics are in place. Effective intermittent social distancing will require widespread surveillance.
New analysis estimates fatality ratio for COVID-19
An analysis (Lancet, March 30) using new statistical approaches found an overall COVID-19 case fatality ratio (percentage of individuals with symptomatic or confirmed COVID-19 who die) in China of 1.38%, with a “substantially higher” estimate of 6.4% for those aged 60 or older. The estimated case fatality ratio for those aged 80 or older was 13.4%. Authors note that while the case fatality ratio for other coronaviruses (SARS and MERS) were higher, the case fatality rate for COVID-19 is “substantially higher” than for H1N1. This model-based analysis focused on fatality and hospitalization due to COVID-19 and could be used to adjust Ohio-specific estimates.An accompanying commentary (Lancet, March 30) contextualizes just how much more dangerous COVID-19 is than seasonal flu. It concludes that “even for those aged 20-29 years, once infected with [COVID-19], the mortality rate is 33 times higher than that from seasonal influenza.” For people aged 60 years and older, the chance of survival is “approximately 95% in the absence of comorbid conditions.”
March 31
Studies of previous infectious diseases shed light on effectiveness of public use of face masks
Current messages to the public about COVID-19 have discouraged use of masks, except for healthcare workers. However, previous research on the effectiveness of masks to reduce the spread of other infectious diseases may suggest that those recommendations should be reconsidered.A randomized control trial (Annals of Internal Medicine, Oct. 6, 2009) found that hand washing and facemasks (together) can reduce influenza transmission if used early after symptom onset of the first person with illness in the household. Facemasks plus hand hygiene was more effective than hand hygiene alone in reducing transmission of influenza.A systematic review (BMJ, Nov. 27, 2007) of the effectiveness of hand washing, masks, gloves and gowns to reduce the spread of SARS found that all methods were effective in reducing (but not eliminating) transmission; N95 masks, other masks and gowns were most effective. N95 masks are extremely important for reducing transmission and protecting healthcare workers, but other types of masks, as well as gowns, gloves and handwashing are also important.
March 26
Model confirms social distancing, quarantining effective in slowing spread of COVID-19
A study (The Lancet Infectious Diseases, March 23, 2020) adapting an influenza simulation model found that implementing the combined intervention of quarantining infected individuals and their family members, workplace distancing and school closure once community transmission has been detected could substantially reduce the number of COVID-19 infections. The study also found that quarantine and workplace distancing should be prioritized over school closure because at the early stage in community COVID-19 exposure, symptomatic children have higher withdrawal rates from school than do symptomatic adults from work.
