COVID 19: Testing and surveillance

HPIO is collecting the latest research so that Ohio policymakers and other stakeholders can make informed decisions on the rapidly evolving COVID-19 pandemic. Regular research updates are mailed to HPIO’s email contact list (click here to join our mailing list and if you are already signed up for our mailing list and do not see the updates, please check your spam folder).


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.”

Smart testing framework and strategies

A report on COVID-19 testing (Center for Infectious Disease Research and Policy (CIDRAP), University of Minnesota, May 20) provides a concise overview of types of tests and the limitations and challenges involved for each. It provides several actionable recommendations for when and how testing should be conducted. The “smart testing” framework offers a concise set of issues policymakers need to address when developing diagnostic and surveillance strategies. The report proposes a “smart testing” approach that accounts for  infrastructure, population, action, interpretation and test type. Molecular, antigen and serology tests are addressed. The report includes the following sections: Testing fundamentals, use cases for COVID-19 testing, infrastructure to support testing and the COVID-19 testing cascade (material capacity, instrument capacity, skilled labor availability, instrument use and availability, result reporting and action steps). The authors call for a blue-ribbon panel to be convened by U.S. Department of Health and Human Services to develop a national strategy for smart testing.

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.


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

Optimal test timing by specimen type

An article on interpreting COVID-19 diagnostic tests (JAMA, May 6) concisely described two types commonly in use for SARS-CoV-2 infections—reverse transcriptase–polymerase chain reaction (RT-PCR) and IgM and IgG enzyme-linked immunosorbent assay (ELISA)—and how the results may vary over time. The article includes a useful diagram that shows when detection is unlikely, when PCR tests can be used and when antibody detection is possible by symptom onset and number of weeks after exposure. The article summarizes available research on the timing of when PCR tests can detect viral RNA by sample type (nasopharyngeal swab, stool, etc.), the accuracy and timing of antibody (serological) tests, and considerations for rapid point-of-care antibody tests.

A prospective assessment of 49 COVID-19 cases (CDC Emerging Infectious Diseases, May 8) estimates the frequency and duration of detectable SARS-CoV-2 RNA in human body fluids. The authors found persistent shedding of virus RNA in all types of samples although there were differences in median time until loss of virus RNA detection. They obtained and tested throat swab, nasopharyngeal swab, sputum, and feces specimens every 3 days for 4 weeks. They then used regression modeling to estimate the time until the loss of SARS-CoV-2 RNA detection in each body fluid. The results show prolonged persistence of SARS-CoV-2 RNA in hospitalized patients with COVID-19. Health professionals should consider these findings in diagnostic recommendations and prevention measures for COVID-19.

Cautions for using big data to drive local decisions

An article on the use of “big data” to measuring social distancing and mobility (Harvard Business Review, May 8) cautions against drawing specific conclusions about local COVID-19 outbreaks. The authors explain that big data analysis should be done in collaboration with epidemiologists and other specialists. The article concludes with suggestions to “read carefully and trust cautiously.” This article provides helpful guidance for policymakers, particularly to respond to members of the public or media who will ask questions about big data analysis published in the media.


May 6

Strategy to increase testing capacity

An article describing a strategy to pool samples for RT-PCR testing (The Lancet Infectious Diseases, April 28) states that the practice could expand the laboratory infrastructure and test kit capacity to screen large numbers of asymptomatic people. If samples are pooled for testing, only in the case of positive pool test results is a work-up of individual samples initiated. These data suggest that pooling of up to 30 samples can increase test capacity with existing equipment and test kits; and detect positive samples with sufficient diagnostic accuracy.


May 4

Symptoms and outcomes in children

A study of children tested in a hospital in Wuhan, China (NEJM, April 23) found that of 1,391 children tested, a total of 171 (12.3%) were confirmed to have SARS-CoV-2. Fever was present in 41.5% of the children. Other common symptoms included cough and sore throat. As of March 8, there was one death in a 10-month-old child, 21 patients were in stable condition in the general ward and 149 were discharged. Asymptomatic infections (15.8%) were not uncommon. Determination of the transmission potential of these asymptomatic patients is important for guiding the development of measures to control the ongoing pandemic.


April 30

Racial and ethnic disparities in COVID-19 patients

A study analyzing the variation in COVID-19 hospitalizations and deaths across the New York City boroughs (JAMA, April 29) found that there was wide variation in both testing and hospitalizations among the geographic areas of the city. The number of COVID-19 tests performed per 100,000 population was highest in Staten Island (5,603), followed by the Bronx (4,599), Brooklyn (2,970), Manhattan (2,844) and Queens (3,800). The number of patients with COVID-19 who were hospitalized per 100,000 population was highest in the Bronx (634) and lowest in Manhattan (331). The number of deaths related to COVID-19 per 100,000 population was also highest in the Bronx (224) and lowest in Manhattan (122). The Bronx, which has the highest proportion of racial/ethnic minorities, the most persons living in poverty and the lowest levels of educational attainment had higher rates of hospitalization and death related to COVID-19 than the other 4 boroughss


April 28

Asymptomatic and presymptomatic cases in congregate settings

Several recent studies of widespread testing of residents in congregate settings such as homeless shelters and nursing homes have found a significant number of positive results for people who were not demonstrating any symptoms of COVID-19.

A study of a COVID-19 outbreak at a homeless shelter in Boston (JAMA Research Letter, April 27) found that universal SARS-CoV-2 testing of shelter residents shortly after the outbreak yielded a 36% positivity rate. The majority of individuals with newly identified infections had no symptoms and no fever at the time of diagnosis, suggesting that symptom screening in homeless shelters may not adequately capture the extent of disease transmission in this high-risk setting. These results support testing of asymptomatic shelter residents if a symptomatic individual with COVID-19 is identified in the same shelter.

A study of SARS-CoV-2 transmission in residents in a skilled nursing facility in King County, Washington (NEJM, April 24) found that, among 76 residents who participated in point-prevalence surveys, 48 (63%) tested positive. Of these 48 residents, 27 (56%) were asymptomatic at the time of testing; 24 subsequently developed symptoms. More than half of residents with positive test results were asymptomatic at the time of testing and most likely contributed to transmission. Transmission from asymptomatic residents infected with SARS-CoV-2 most likely contributed to the rapid and extensive spread of infection to other residents and staff. Infection-control strategies focused solely on symptomatic residents were not sufficient to prevent transmission after SARS-CoV-2 introduction into this facility.

Reliability and accuracy of antibody tests

A study evaluating the reliability and accuracy of serological tests (COVID-19 Testing Project, April 24) examined 11 test currently on the market and one in-house test. Tests examined include10 lateral flow assays: Biomedomics, Bioperfectus, DecomBio, DeepBlue, Innovita, Premier, Sure, UCP, VivaChek, Wondfo and 2 enzyme-linked immonosorbent assays: Epitope and in-house. Researchers examined the percent of positive specimens from people who had a positive PCR test by days since symptom onset as well as the percent of positive specimens from people who were positive for other viruses and/or had a negative PCR result. The researchers note that their study reinforces the need for additional research using standardized samples.


April 27

Testing strategies

report outlining recommendations for a national approach to serological testing (Johns Hopkins Bloomberg School of Public Health Center for Health Security, April 22) describes the potential uses of serology (antibody) tests, areas of uncertainty where additional research is needed and examples from other countries now beginning to make use of these tests. While serology testing is an important tool, validated, accurate tests are currently in short supply. The report is a useful summary of what is currently known about antibody tests and what unanswered research questions and ethical considerations remain. The report includes a section called “Actions for Leaders,” which specifies policy actions that could take place at the state and local levels. These include: (1) plan, conduct and oversee public and private testing, (2) use serology to inform ongoing contact tracing and (3) ensure that serology surveillance is available for vulnerable and underserved populations.
 
model for exploring the effectiveness of alternative testing strategies for COVID-19 (Imperial College, April 23) found that weekly screening of healthcare workers and other at-risk groups using point-of-care tests for infection, irrespective of symptoms, is estimated to reduce their contribution to transmission by 25-33%, on top of reductions achieved by self-isolation following symptoms. Widespread PCR testing in the general population is unlikely to limit transmission more than contact tracing and quarantine based on symptoms alone, but could allow earlier release of contacts from quarantine. The findings of the report suggest that COVID testing is essential for pandemic surveillance but its direct contribution to the prevention of transmission is most effective if implemented with patients, healthcare workers and other high-risk groups.

April 23

Insights on modeling the COVID-19 pandemic

study to determine the optimal lockdown policy for COVID-19 (National Bureau of Economic Research, April 2020) combines tactics for reducing pandemic fatalities while minimizing the economic costs of the lockdown. The researchers use an epidemiological model to estimate fatalities and assume that testing is available that allows those who recover to go back to work. The economic cost analysis includes economic activity lost during a lockdown, as well as costs due to deaths. The authors conclude that the optimal policy includes a severe lockdown beginning two weeks after the outbreak, covers 60% of the population after a month, and is gradually withdrawn covering 20% of the population after 3 months. They also find that the absence of testing increases the economic costs of the lockdown. The authors note that because this is a modeling study, it makes several assumptions regarding transmission, fatality rates, economic conditions, the value of life and other factors. It does not capture the actual effectiveness of social distancing policies or effectiveness of clinical care. In addition, long-term economic impacts are not assessed.
A perspective piece on mathematical and epidemiological models (JAMA, April 16) discusses some limitations and challenges to COVID-19 modeling, and in particular examines the widely cited IHME model. The many unknown factors related to COVID-19 have made modeling challenging, with wide variations in estimates from numerous sources. The authors make several recommendations: 1) models should be dynamic, 2) assumptions used should be disclosed, 3) all should provide ranges of possibilities, 4) models should incorporate new data as it becomes available and 5) public reporting “must be appropriately circumspect and include key caveats.”

April 21

Deploying COVID-19 blood tests

commentary on the availability and usefulness of antibody tests for COVID-19 (JAMA, April 17) argues that although these tests will be critical in the weeks and months ahead, they must be deployed appropriately and with an acknowledgment of unanswered questions. Some serology tests identify how many antibodies an individual has, while others, such as lateral flow assays, provide a simple positive or negative result with no quantitative information. One lateral flow assay has been granted Emergency Use Authorization by the FDA. While these tests can be useful for some limited purposes, such as population-level disease surveillance, they should not be used as the sole basis to diagnose or exclude SARS-CoV-2 infection or to inform patients of infection status. However, several companies are marketing lateral flow assays as rapid point-of-care tests. Additionally, allowing people to leave quarantine based on their antibody status assumes that past infection guards against reinfection, something that researchers have said is likely, but not yet well defined.
commentary on what is needed to lift social distancing restrictions (Harvard Global Health Institute, April 18) estimates that the number of virologic tests needed nationally every day is, at a minimum, 500,000, though we likely need many more. The authors present approaches to estimating the number of tests needed, including the pros and cons of each approach. Testing is critical in order to estimate the number of COVID-19 cases in the U.S., isolate the individuals who test positive and trace the contacts of those individuals to prevent further spread. If the U.S. cannot test at least 500,000 people daily by May 1, the authors conclude that it will be difficult for the economy to be fully reopened.

Symptom screening for COVID-19

study of healthcare personnel in Washington (JAMA, April 17) found that of 48 infected workers who were interviewed, the most common initial symptoms of COVID-19 were cough (50.0%), fever (41.7%) and muscle aches (35.4%). Eight of those interviewed (16.7%) did not report fever, cough, shortness of breath or sore throat at symptom onset; among this group, the most common symptoms were chills, muscle ache, nasal congestion and malaise. Among those interviewed, 64.6% reported working a median of 2 days while exhibiting symptoms.
The authors concluded that screening only for fever, cough, shortness of breath or sore throat might have missed 17% of symptomatic healthcare workers at the time of illness onset; and expanding criteria for symptoms screening to include muscle soreness and chills may still have missed 10%.

Influenza and COVID-19 spread

study of COVID-19 diagnosis in the U.S. (MedRxIVApril 14) found a surge of non-influenza illness above the seasonal average is correlated with COVID-19 case counts across states. The surge of cases corresponds to at least 28 million presumed symptomatic COVID-19 patients across the U.S. during the three week period from March 8 to March 28. The authors caution that these estimates should be verified with antibody testing. The analysis suggests that COVID-19 has spread rapidly throughout the U.S. since January 15 and is likely accompanied by a large undiagnosed population of potential COVID-19 outpatients with presumably milder clinical symptoms than estimated from prior studies of COVID-19 inpatients.

April 20

SARS-CoV-2 prevalence and co-infection rates

A study on COVID-19 antibodies (MedRxIV, April 11) tested residents of a California county for antibodies to SARS-CoV-2. Participants were recruited using Facebook ads targeting a representative sample of the county by demographic and geographic characteristics. Under three testing scenarios, the population prevalence of COVID-19 in Santa Clara ranged from 2.49% to 4.16%. These prevalence estimates represent a range between 48,000 and 81,000 people infected in Santa Clara County by early April, which is 50-85 times higher than the number of confirmed cases in the county. This research suggests that SARS-CoV-2 infection may be much more widespread than indicated by the number of confirmed cases. Population prevalence estimates, like the one in this study, can be used to calibrate epidemic and mortality projections. The authors noted that the sampling strategy was not random and selected individuals with access to Facebook and a car to attend drive-through testing sites. This resulted in an over representation of white women between the ages of 19 and 64, and an under representation of Hispanic and Asian populations, relative to that community.
An analysis of patients with COVID-19 symptoms (JAMA, April 15) found that 116 of the 1,217 patients tested were positive for SARS-CoV-2. Of those who tested positive for SARS-CoV-2, 20.7% were also positive for one or more other pathogens. The researchers note that this is a higher percentage than had been reported previously in China. They conclude that “routine testing for non-SARS-CoV-2 respiratory pathogens during the COVID-19 pandemic is unlikely to provide clinical benefit unless a positive result would change disease management.” This finding could be useful in guiding testing protocols for people with symptoms in that a positive test for another pathogen does not necessarily rule out the presence of SARS-CoV-2.

April 16

COVID-19 patients can spread the virus days before having symptoms

An analysis of viral shedding in COVID-19 patients (Nature Medicine, April 15) estimated that 44% of transmissions occurred when a patient was still pre-symptomatic. The researchers observed high viral load in COVID-19 patients immediately after symptoms presented, which tapered off over a period of approximately 21 days. The authors also found that COVID-19 patients become infectious 2.3 days before symptom onset, with a peak in infectiousness around 0.7 days before symptom onset. Because of the high likelihood of transmission before symptom onset, disease control measures should be adjusted to account for probable pre-symptomatic transmission. The finding could also impact criteria for contact tracing to capture potential transmission events 2 to 3 days before symptom onset.

Digital contact tracing faces political, cultural barriers in U.S.

Compared to how several East Asian countries have deployed technology to conduct effective contact tracing, cultural and political differences in the U.S. may limit the use of these technologies, according to a Harvard Business Review report (April 15). The authors explore three critical conditions that might each present difficult dilemmas for Western democracies: 1) Adoption of technologies (whether they are encouraged or made mandatory), 2) Digital infrastructure enabled and activated by the government and 3) Seamless data sharing between government and business that may afford few privacy protections. While digital contact tracing is faster and likely more effective than traditional methods, barriers such as privacy concerns and the ability of public and private entities to share data would need to be overcome in order to deploy this technology in Ohio.


April 14

Re-detection of SARS-CoV-2 in discharged COVID-19 patients

A study of patients recovering from COVID-19 (medRxiv, March 30) found that some may test positive again after discharge. The study’s authors found that 14.5% of patients studied (38 out of 262) tested positive after discharge. When re-admitted to the hospital, these patients showed no obvious clinical symptoms or disease progression. The patients who tested positive post discharge were young and had mild cases. The authors concluded that more sensitive RNA detection methods are required to monitor these patients during follow-up, as some testing may not be sensitive enough to detect lingering levels of the virus.

April 13

Balancing COVID-19 restrictions and testing with civil liberties

An analysis of restrictions aimed at slowing the spread of COVID-19 (New England Journal of Medicine, April 9) explores the legal and public policy precedents for balancing public health imperatives and civil liberties during a public health emergency. The authors explain that the COVID-19 outbreak is different in many ways from the outbreaks that were the basis of these precedents. The authors argue that decisions to lift the severe restrictions currently in place in the U.S. should be based on “person-level information” gathered through a “population-wide program of disease testing and surveillance.” This would enable policymakers to tailor restrictions to affected individuals and communities, relieving undue burden on others. This approach has noted limitations, including the current lack of access to widespread testing and the need for personal protective equipment.
A blog entry posted on the website of Health Affairs(April 7) discusses how widespread home testing could result in a tiered approach to lifting social isolation restrictions and reopening the economy. The authors suggest that two different tests would need to be broadly disseminated to the public: an antibody test to reveal coronavirus immunity and a viral test to determine current infection status. Those who test positive for the virus can self-quarantine, while those who test positive for the antibodies can return to work. Rapid antibody and viral tests exist, including a finger prick test for antibodies that delivers results in 10-15 minutes. Authors also suggest that an “immunization passport” could be developed, such as a secure app that connects test results to personal identification markers, so that health care workers and employers can confirm an individual’s immune status.

Neurologic symptoms found in patients with COVID-19

new study(JAMA, April 10) found that patients with COVID-19 commonly have neurologic manifestations. The study of 214 patients found that 36% reported neurologic symptoms. Among patients with severe infections, 6% reported acute cerebrovascular diseases, 15% reported impaired consciousness and 19% reported muscle injury. The authors suggest that when seeing patients with neurologic manifestations, such as dizziness, headache or loss of smell or taste, clinicians should suspect COVID-19 infection as a possible diagnosis to avoid delayed diagnosis or misdiagnosis and to accelerate treatment and prevent further transmission.

 


 

April 9

Analysis of COVID-19 hospitalizations illuminates disparities

The latest edition of the Morbidity and Mortality Weekly Report includes
a report (CDC, April 8) on the demographics of COVID-19 hospital patients admitted in March. Findings suggest that older adults have elevated rates of COVID-19-associated hospitalization and the majority of persons hospitalized with COVID-19 have underlying medical conditions. The data suggests that males may be disproportionately affected by COVID-19 and that black populations might also be disproportionately affected by COVID-19.

Wastewater testing may provide COVID-19 early warning

Researchers have begun testing wastewater for traces of SARS-CoV-2, a technique that may serve as an early-warning system of a COVID-19 outbreak or supplement clinical testing in areas where it is limited, according to a new study (medRxiv, April 7). Researchers tested wastewater collected at a major urban treatment facility in Massachusetts and found the presence of SARS-CoV-2 –the virus that causes the COVID–19 disease-at high levels. According to news coverage, researchers estimated that at least 2,300 people were infected with COVID-19 in the area around the treatment facility, when there were only 446 cases officially reported.

April 8

CDC launching multiple COVID-19 blood test studies

There have been multiple recent media reports about emerging antibody tests to detect whether people have been exposed to the virus that causes COVID-19 (for example, New York Times, April 2, 2020 and NBC News, April 4, 2020). This Stat article reports that the CDC will conduct three studies focused on antibody testing. The first study, which is already underway, is examining blood samples from people who have not been diagnosed with COVID-19 in “hot spots.” The second, which the CDC hopes to start during the summer, will focus on samples from other parts of the country. The third study will focus on special populations, initially healthcare workers. All of these studies, called sero-surveys, will “involve drawing blood from people never diagnosed as a case to look for antibodies to the virus.” They will include a representative sample of a population, including people of various ages. The development and use of antibody testing will be important for decision making and planning.

April 6

Development of antibody tests

A report summarizing the current state of development of antibody tests for COVID-19 (Lancet, April 4) found that widespread availability of such tests will be key for decision making related to public policy. Antibody tests will identify who has developed immunity to the virus. Labs and researchers creating these tests can use emergency use authorization issued by the FDA to expedite making them available. The technology for antibody tests is “generally harder to get right” compared to the tests for detecting viral RNA, the authors found. Several tests are in development, but scaling up production to meet global demand will be challenging.

April 2

Strategies for increasing contact tracing

New articles shed light on how the United States can better slow the spread of coronavirus and treat those infected with the virus.
New analysis of the infectiousness of the coronavirus (Science, March 31) finds that traditional manual contact tracing procedures are not fast enough to effectively stop the spread of the virus. To improve infection control, the researchers propose a system for instant digital contact tracing through a mobile phone app. This app keeps a temporary record of proximity events between individuals and can immediately alert recent close contacts of diagnosed cases and prompt them to self-isolate. The model predicts that this approach could reduce transmission enough to suppress the COVID-19 epidemic. The authors report that similar apps have been deployed in China and South Korea, and that this approach allows countries to target interventions only to those at risk, without need for lock-downs.
Another article examines the potential role of community health workers(World Economic Forum, March 31) in responding to the COVID-19 pandemicPeople who are unemployed can be trained as community health workers and then could be deployed to address COVID-19 outbreaks, particularly to assist with preventing, detecting and responding to the disease in the community. For example, community health workers could support contact tracing, symptom reporting and monitoring of contacts of COVID-19 patients to ensure access to testing and treatment for people who develop signs and symptoms. An example of this work can be found in the deployment of community health workers in Liberia.

April 1

Experts suggest considerations for older physicians, nurses treating COVID-19 patients

Using estimates based on Census data, the authors of a new commentary (JAMA, March 30) note that a substantial number of physicians and nurses are age 55 or older, an age group particularly susceptible to complications from COVID-19. For example, in the Columbus, Ohio hospital referral region, 20.9% of nurses and physicians are estimated to be age 55 or older. Given that the severity of COVID-19 complications is higher among older adults, the authors suggest that “hospitals and other care delivery organizations, including state and local health departments, should carefully consider how best to protect and preserve their workforce, with careful consideration involving older physicians and nurses.” As retired clinicians are asked to re-enter the workforce to respond to COVID-19, consideration should also be given to the types of roles these practitioners are asked to fill.

March 26

WHO publishes updated guidance for COVID-19 testing
The World Health Organization recently released new guidance for COVID-19 testing(World Health Organization, March 22, 2020) recommending prioritizing available testing capacity for vulnerable populations and healthcare workers. Additional priorities for testing include the first suspected cases at facilities at high risk for rapid transmission such as “…long-term living facilities, prisons, [and] hospitals.” WHO also specifies indicators for tracking testing.
Given the limited supply of tests in the United States overall and in Ohio, this guidance can be used to set criteria for prioritizing which Ohioans get access to tests. The tracking indicators may also be useful for establishing a system for tracking tests conducted in Ohio.

March 25

Screening for fever not sufficient for COVID-19 identification

It has been widely communicated that one of the primary symptoms of COVID-19 is a fever. However, new data adds important context.

A new study (Annals of Internal Medicine, March 10, 2020) of COVID-19 patients in Wuhan, China found that patients did not develop a fever for a median of 5.7 days after being infected. That finding can inform public education about social distancing, self-isolation and quarantine, as well as contact tracing conducted by local health departments. In addition, the 5.7-day median incubation period for fever onset indicates that using temperature checks as a screening measure may miss many cases.

Another study (New England Journal of Medicine, Feb. 28, 2020) of COVID-19 patients in mainland China found that only 43.8% of patients had a fever upon hospital admission. The study also found that current smokers were more likely to have severe disease than non-smokers. This is relevant given Ohio’s relatively high adult smoking rate.