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It is Time to Address Airborne Transmission of COVID-19
Lidia Morawska, Donald K Milton
Clinical Infectious Diseases, ciaa939, https://doi.org/10.1093/cid/ciaa939
Commentary
We appeal to the medical community and to the relevant national and international bodies to recognize the potential for airborne spread of COVID-19. There is significant potential for inhalation exposure to viruses in microscopic respiratory droplets (microdroplets) at short to medium distances (up to several meters, or room scale), and we are advocating for the use of preventive measures to mitigate this route of airborne transmission.
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We are concerned that the lack of recognition of the risk of airborne transmission of COVID-19 and the lack of clear recommendations on the control measures against the airborne virus will have significant consequences: people may think that they are fully protected by adhering to the current recommendations, but in fact, additional airborne interventions are needed for further reduction of infection risk.
This matter is of heightened significance now, when countries are re-opening following lockdowns - bringing people back to workplaces and students back to schools, colleges, and universities. We hope that our statement will raise awareness that airborne transmission of COVID-19 is a real risk and that control measures, as outlined above, must be added to the other precautions taken, to reduce the severity of the pandemic and save lives.
It is Time to Address Airborne Transmission of COVID-19
TRUMP COVID VIRUS 2020
Subject: GAO COVID-19 : Opportunities to Improve Federal Response and Recovery Efforts
GAO highlights opportunities to improve federal COVID-19 response, recovery efforts
© Shutterstock
In accordance with the CARES Act containing a provision for the Government Accountability Office (GAO) to report on ongoing COVID-19 monitoring and oversight efforts, six recommendations have been issued.
The GAO indicated its recent analysis examined key actions the federal government has taken to address the pandemic and evolving lessons learned relevant to the nation’s response to pandemics.
Per the GAO, four relief laws were enacted as of June 2020 in response to COVID-19, including the CARES Act, in March 2020, with the measures having appropriated $2.6 trillion across the government.
The Paycheck Protection Program (PPP); Economic Stabilization and Assistance to Distressed Sectors; unemployment insurance; economic impact payments; Public Health and Social Services Emergency Fund; and Coronavirus Relief Fund accounted for 86 percent of the appropriations, the GAO indicated.
GAO identified several challenges related to the federal response to the crisis, officials said, noting the Centers for Disease Control and Prevention (CDC) reported incomplete and inconsistent data from state and jurisdictional health departments on the amount of viral testing occurring nationwide, making it more difficult to track and know the number of infections, mitigate their effects, and inform decisions on reopening communities; the nationwide need for critical supplies to respond to COVID-19 quickly exceeded the quantity of supplies contained in the Strategic National Stockpile; PPP borrowers and lenders raised several questions about the program and eligibility criteria, but after efforts to address the concerns, questions and confusion remained; and the Department of Labor currently has no mechanism in place to capture information in real-time about unemployment insurance claimants who may receive wages paid from PPP loan proceeds.
The GAO has offered the following recommendations, including urging Congress to take legislative action to require the Secretary of Transportation to work with relevant agencies and stakeholders, to develop a national aviation preparedness plan to ensure safeguards are in place to limit the spread of communicable disease threats from abroad while at the same time minimizing any unnecessary interference with travel and trade; provide agencies access to the Social Security Administration’s more complete set of death data and require that the Department of the Treasury consistently use it; and as a means of ensuring federal funding is targeted and timely, the GAO has urged Congress to use the agency’s Federal Medical Assistance Percentage formula for any future changes to the Federal Medical Assistance Percentage during the current or any future economic downturn.
Executive Action recommendations issued by the GAO include the Secretary of Labor immediately providing information to state unemployment agencies specifically addressing Paycheck Protection Program loans and the risk of improper payments associated with the loans; the Commissioner of Internal Revenue should consider cost-effective options for notifying ineligible recipients on how to return payments; and the Administrator of the Small Business Administration should develop and implement plans to identify and respond to risks in the Paycheck Protection Program to ensure program integrity, achieve program effectiveness and address potential fraud.
Energy and Commerce Chairman Frank Pallone, Jr. (D-NJ) said the GAO’s report provided a detailed accounting of the Trump Administration’s handling of the coronavirus pandemic.
“The report finds routine inconsistencies in the Administration’s testing data, perpetual shortages of critical supplies, and poorly coordinated response efforts that allowed the virus to spread at alarming rates,” Pallone said in response to the report. “The GAO’s findings echo concerns we heard from governors at a hearing earlier this month about how the federal government has hampered state efforts to deal with shortages of critical supplies. It raises questions about allocating supplies from the Strategic National Stockpile and how it will ensure the Stockpile is replenished to continue fighting COVID-19 infections.”
GAO COVID-19 : Opportunities to Improve Federal Response and Recovery Efforts
Report to the Congress
GAO-20-625; PUBLISHED: JUN 25, 2020 . PUBLICLY RELEASED:JUN 25, 2020
tRump and people of color, and mandated death by executive order?
June 19, 2020
Their findings indicate that COVID-19 outbreaks among food production workers “may exacerbate the disproportionate impact COVID-19 is having on people of color and widen underlying health, social, and economic disparities,” the authors noted.
The federal government has designated the food and agricultural sector as part of the “essential critical infrastructure,” industries that “have a special responsibility in these times to continue operations.” A Presidential Executive Order issued April 28 invoked the Defense Production Act to keep meat processing plants open. Moreover, on May 19, the US Department of Agriculture and the US Food and Drug Administration said the federal government could authorize similar actions to keep companies that manufacture, process, pack, hold, or grow or harvest food open and running.
- CDC recommends that people wear cloth face coverings in public settings when around people outside of their household, especially when other social distancing measures are difficult to maintain.
- Cloth face coverings may help prevent people who have COVID-19 from spreading the virus to others.
- Cloth face coverings are most likely to reduce the spread of COVID-19 when they are widely used by people in public settings.
- Cloth face coverings should NOT be worn by children under the age of 2 or anyone who has trouble breathing, is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.
Evidence for Effectiveness of Cloth Face Coverings
Cloth face coverings are recommended as a simple barrier to help prevent respiratory droplets from traveling into the air and onto other people when the person wearing the cloth face covering coughs, sneezes, talks, or raises their voice. This is called source control. This recommendation is based on what we know about the role respiratory droplets play in the spread of the virus that causes COVID-19, paired with emerging evidence from clinical and laboratory studies that shows cloth face coverings reduce the spray of droplets when worn over the nose and mouth. COVID-19 spreads mainly among people who are in close contact with one another (within about 6 feet), so the use of cloth face coverings is particularly important in settings where people are close to each other or where social distancing is difficult to maintain.
Who Should Wear A Cloth Face Covering?
General public
- CDC recommends all people 2 years of age and older wear a cloth face covering in public settings when around people outside of their household, especially when other social distancing measures are difficult to
- COVID-19 can be spread by people who do not have symptoms and do not know that they are infected. That’s why it’s important for everyone to wear cloth face coverings in public settings and practice social distancing (staying at least 6 feet away from other people).
- While cloth face coverings are strongly encouraged to reduce the spread of COVID-19, CDC recognizes there are specific instances when wearing a cloth face covering may not be feasible. In these instances, adaptations and alternatives should be considered whenever possible (see below for examples).
People who know or think they might have COVID-19
- If you are sick with COVID-19 or think you might have COVID-19, do not visit public areas. Stay home except to get medical care. As much as possible stay in a specific room and away from other people and pets in your home. If you need to be around other people or animals, wear a cloth face covering (including in your home).
- The cloth face covering helps prevent a person who is sick from spreading the virus to others. It helps keep respiratory droplets contained and from reaching other people.
Caregivers of people with COVID-19
- Those caring for someone who is sick with COVID-19 at home or in a non-healthcare setting may also wear a cloth face covering. However, the protective effects—how well the cloth face covering protects healthy people from breathing in the virus—are unknown. To prevent getting sick, caregivers should also continue to practice everyday preventive actions: avoid close contact as much as possible, clean hands often; avoid touching your eyes, nose, and mouth with unwashed hands; and frequently clean and disinfect surfaces.
Who Should Not Wear a Cloth Face Covering
Cloth face coverings should not be worn by:
- Children younger than 2 years old
- Anyone who has trouble breathing
- Anyone who is unconscious, incapacitated, or otherwise unable to remove the cloth face covering without assistance
Feasibility and Adaptations
CDC recognizes that wearing cloth face coverings may not be possible in every situation or for some people. In some situations, wearing a cloth face covering may exacerbate a physical or mental health condition, lead to a medical emergency, or introduce significant safety concerns. Adaptations and alternatives should be considered whenever possible to increase the feasibility of wearing a cloth face covering or to reduce the risk of COVID-19 spreading if it is not possible to wear one.
For example,
- Individuals who are deaf or hard of hearing—or those who care for or interact with a person who is hearing impaired—may be unable to wear cloth face coverings if they rely on lipreading to communicate. In this situation, consider using a clear face covering. If a clear face covering isn’t available, consider whether you can use written communication, use closed captioning, or decrease background noise to make communication possible while wearing a cloth face covering that blocks your lips.
- Some individuals with developmental disabilities, sensory integration concerns or tactile sensitivities, certain mental health conditions, or limited cognitive ability may have a negative reaction to wearing a cloth face covering. These individuals may consult with their healthcare provider as part of the decision to wear a cloth face covering.
- Younger children (e.g., preschool or early elementary aged) may be unable to wear a cloth face covering properly, particularly for an extended period of time. Wearing of cloth face coverings may be prioritized at times when it is difficult to maintain a distance of 6 feet from others (e.g., during carpool drop off or pick up, or when standing in line at school). Ensuring proper cloth face covering size and fit and providing children with frequent reminders and education on the importance and proper wear of cloth face coverings may help address these issues.
- Individuals should not wear cloth face coverings while engaged in activities that may cause the cloth face covering to become wet, like when swimming at the beach or pool. A wet cloth face covering may make it difficult to breathe. For activities like swimming, it is particularly important to maintain physical distance from others when in the water.
- Individuals who are engaged in high intensity activities, like running, may not be able to wear a cloth face covering if it causes difficulty breathing. If unable to wear a cloth face covering, consider conducting the activity in a location with greater ventilation and air exchange (for instance, outdoors versus indoors) and where it is possible to maintain physical distance from others.
- Individuals who work in a setting where cloth face coverings may increase the risk of heat-related illness or cause safety concerns due to introduction of a hazard (for instance, straps getting caught in machinery) may consult with an occupational safety and health professional to determine the appropriate face covering for their setting. Outdoor workers may prioritize use of cloth face coverings when in close contact with other people, like during group travel or shift meetings, and remove face coverings when social distancing is possible. Find more information here and below.
Cloth face coverings are a critical preventive measure and are most essential in times when social distancing is difficult. If cloth face coverings cannot be used, make sure to take other measures to reduce the risk of COVID-19 spread, including social distancing, frequent hand washing, and cleaning and disinfecting frequently touched surfaces.
Face Shields
It is not known if face shields provide any benefit as source control to protect others from the spray of respiratory particles. CDC does not recommend use of face shields for normal everyday activities or as a substitute for cloth face coverings. Some people may choose to use a face shield when sustained close contact with other people is expected. If face shields are used without a mask, they should wrap around the sides of the wearer’s face and extend to below the chin. Disposable face shields should only be worn for a single use. Reusable face shields should be cleaned and disinfected after each use. Plastic face shields for newborns and infants are NOT recommended.
Surgical Masks
Cloth face coverings are not surgical masks or respirators. Currently, those are critical supplies that should continue to be reserved for healthcare workers and other medical first responders, as recommended by current CDC guidance. Cloth face coverings also are not appropriate substitutes for them in workplaces where masks or respirators are recommended or required and available.
Recent Studies:
- Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany. The New England journal of medicine. 2020;382(10):970-971. PMID: 32003551
- Zou L, Ruan F, Huang M, et al. SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. The New England journal of medicine. 2020;382(12):1177-1179. PMID: 32074444
- Pan X, Chen D, Xia Y, et al. Asymptomatic cases in a family cluster with SARS-CoV-2 infection. The Lancet Infectious diseases. 2020. PMID: 32087116
- Bai Y, Yao L, Wei T, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. Jama. 2020. PMID: 32083643
- Kimball A HK, Arons M, et al. Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility — King County, Washington, March 2020. MMWR Morbidity and mortality weekly report. 2020; ePub: 27 March 2020. PMID: 32240128
- Wei WE LZ, Chiew CJ, Yong SE, Toh MP, Lee VJ. Presymptomatic Transmission of SARS-CoV-2 — Singapore, January 23–March 16, 2020. MMWR Morbidity and Mortality Weekly Report. 2020;ePub: 1 April 2020. PMID: 32271722
- Li R, Pei S, Chen B, et al. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science (New York, NY). 2020. PMID: 32179701
- Furukawa NW, Brooks JT, Sobel J. Evidence Supporting Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 While Presymptomatic or Asymptomatic [published online ahead of print, 2020 May 4]. Emerg Infect Dis. 2020;26(7):10.3201/eid2607.201595. Link
- Oran DP, Topol Prevalence of Asymptomatic SARS-CoV-2 Infection: A Narrative Review [published online ahead of print, 2020 Jun 3]. Ann Intern Med. 2020;M20-3012. PMID: 32491919
- National Academies of Sciences, Engineering, and Medicine. 2020. Rapid Expert Consultation on the Possibility of Bioaerosol Spread of SARS-CoV-2 for the COVID-19 Pandemic (April 1, 2020). Washington, DC: The National Academies Press. https://doi.org/10.17226/25769.
- Schwartz KL, Murti M, Finkelstein M, et al. Lack of COVID-19 transmission on an international flight. CMAJ. 2020;192(15):E410. PMID: 32392504
- Anfinrud P, Stadnytskyi V, Bax CE, Bax A. Visualizing Speech-Generated Oral Fluid Droplets with Laser Light Scattering. N Engl J Med. 2020 Apr 15. doi:10.1056/NEJMc2007800. PMID: 32294341
- Davies A, Thompson KA, Giri K, Kafatos G, Walker J, Bennett A. Testing the efficacy of homemade masks: would they protect in an influenza pandemic? Disaster Med Public Health Prep. 2013;7(4):413-8. PMID: 24229526
- Konda A, Prakash A, Moss GA, Schmoldt M, Grant GD, Guha S. Aerosol Filtration Efficiency of Common Fabrics Used in Respiratory Cloth Masks. ACS Nano. 2020 Apr 24. PMID: 32329337
- Aydin O, Emon B, Saif MTA. Performance of fabrics for home-made masks against spread of respiratory infection through droplets: a quantitative mechanistic study. medRxiv preprint doi: https://doi.org/10.1101/2020.04.19.20071779, posted April 24, 2020.
- Ma QX, Shan H, Zhang HL, Li GM, Yang RM, Chen JM. Potential utilities of mask-wearing and instant hand hygiene for fighting SARS-CoV-2. J Med Virol. 2020. PMID: 32232986
Identifying airborne transmission as the dominant route for the spread of COVID-19
Renyi Zhanga,b,1, Yixin Lib, Annie L. Zhangc, Yuan Wangd, and Mario J. Molinae,1
aDepartment of Atmospheric Sciences, Texas A&M University, College Station, TX 77843; bDepartment of Chemistry, Texas A&M University, College Station, TX 77843; cDepartment of Chemistry, College of Natural Sciences, The University of Texas at Austin, Austin, TX 78712; dDivision of Geological and Planetary Sciences, California Institute of Technology, Pasadena, CA 91125; and eDepartment of Chemistry and Biochemistry, University of California San Diego, La Jolla, CA 92093
Contributed by Mario J. Molina, May 16, 2020 (sent for review May 14, 2020; reviewed by Manish Shrivastava and Tong Zhu)
Various mitigation measures have been implemented to fight the coronavirus disease 2019 (COVID-19) pandemic, including widely adopted social distancing and mandated face covering. However, assessing the effectiveness of those intervention practices hinges on the understanding of virus transmission, which remains uncer- tain. Here we show that airborne transmission is highly virulent and represents the dominant route to spread the disease. By analyzing the trend and mitigation measures in Wuhan, China, Italy, and New York City, from January 23 to May 9, 2020, we illustrate that the impacts of mitigation measures are discernable from the trends of the pandemic.
Our analysis reveals that the difference with and without mandated face covering represents the determinant in shaping the pandemic trends in the three epicenters.
This protective measure alone significantly reduced the number of infections, that is, by over 78,000 in Italy from April 6 to May 9 and over 66,000 in New York City from April 17 to May 9. Other mitigation measures, such as social distancing implemented in the United States, are in- sufficient by themselves in protecting the public. We conclude that wearing of face masks in public corresponds to the most effective means to prevent interhuman transmission, and this inexpensive practice, in conjunction with simultaneous social distancing, quaran- tine, and contact tracing, represents the most likely fighting oppor- tunity to stop the COVID-19 pandemic. Our work also highlights the fact that sound science is essential in decision-making for the cur- rent and future public health pandemics.
Significance
We have elucidated the transmission pathways of coronavirus disease 2019 (COVID-19) by analyzing the trend and mitigation measures in the three epicenters. Our results show that the airborne transmission route is highly virulent and dominant for the spread of COVID-19. The mitigation measures are discern- able from the trends of the pandemic. Our analysis reveals that the difference with and without mandated face covering rep- resents the determinant in shaping the trends of the pandemic. This protective measure significantly reduces the number of infections. Other mitigation measures, such as social distancing implemented in the United States, are insufficient by them- selves in protecting the public. Our work also highlights the necessity that sound science is essential in decision-making for the current and future public health pandemics.
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Conclusions
The inadequate knowledge on virus transmission has inevitably hindered development of effective mitigation policies and resulted in unstoppable propagation of the COVID-19 pandemic (Figs. 1–3). In this work, we show that airborne transmission, particularly via nascent aerosols from human atomization, is highly virulent and represents the dominant route for the transmission of this disease. However, the importance of air- borne transmission has not been considered in establishment of mitigation measures by government authorities (1, 20). Specifi- cally, while the WHO and the US Centers for Disease Control and Prevention (CDC) have emphasized the prevention of contact transmission, both WHO and CDC have largely ignored the importance of the airborne transmission route (1, 20). The current mitigation measures, such as social distancing, quaran- tine, and isolation implemented in the United States, are in- sufficient by themselves in protecting the public. Our analysis reveals that the difference with and without mandated face covering represents the determinant in shaping the trends of the pandemic worldwide. We conclude that wearing of face masks in public corresponds to the most effective means to prevent interhuman transmission, and this inexpensive practice, in con- junction with extensive testing, quarantine, and contact tracking, poses the most probable fighting opportunity to stop the COVID-19 pandemic, prior to the development of a vaccine. It is also important to emphasize that sound science should be ef- fectively communicated to policy makers and should constitute the prime foundation in decision-making amid this pandemic. Implementing policies without a scientific basis could lead to catastrophic consequences, particularly in light of attempts to reopen the economy in many countries. Clearly, integration be- tween science and policy is crucial to formulation of effective emergency responses by policy makers and preparedness by the public for the current and future public health pandemics.
The effect of large-scale anti-contagion policies on the COVID-19 pandemic
Solomon Hsiang, Daniel Allen, Sébastien Annan-Phan, Kendon Bell, Ian Bolliger, Trinetta Chong, Hannah Druckenmiller, Luna Yue Huang, Andrew Hultgren, Emma Krasovich, Peiley Lau, Jaecheol Lee, Esther Rolf, Jeanette Tseng & Tiffany Wu
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Although unedited, the content has been subjected to preliminary formatting. Nature is providing this early version of the typeset paper as a service to our authors and readers. The text and fgures will undergo copyediting and a proof review before the paper is published in its fnal form. Please note that during the production process errors may be discovered which could afect the content, and all legal disclaimers apply.
Received: 22 March 2020
Accepted: 26 May 2020
Accelerated Article Preview Published
online 8 June 2020
Cite this article as: Hsiang, S. et al. The effect of large-scale anti-contagion policies on the COVID-19 pandemic. Nature https://doi. org/10.1038/s41586-020-2404-8 (2020).
Governments around the world are responding to the novel coronavirus (COVID-19) pandemic1 with unprecedented policies designed to slow the growth rate of infections. Many actions, such as closing schools and restricting populations to their homes, impose large and visible costs on society, but their benefts cannot be directly observed and are currently understood only through process-based simulations2–4 . Here, we compile new data on 1,717 local, regional, and national non-pharmaceutical interventions deployed in the ongoing pandemic across localities in China, South Korea, Italy, Iran, France, and the United States (US). We then apply reduced-form econometric methods, commonly used to measure the efect of policies on economic growth5,6 , to empirically evaluate the efect that these anti-contagion policies have had on the growth rate of infections. In the absence of policy actions, we estimate that early infections of COVID-19 exhibit exponential growth rates of roughly 38% per day. We fnd that anti-contagion policies have signifcantly and substantially slowed this growth. Some policies have diferent impacts on diferent populations, but we obtain consistent evidence that the policy packages now deployed are achieving large, benefcial, and measurable health outcomes. We estimate that across these six countries, interventions prevented or delayed on the order of 62 million confrmed cases, corresponding to averting roughly 530 million total infections. These fndings may help inform whether or when these policies should be deployed, intensifed, or lifted, and they can support decision-making in the other 180+ countries where COVID-19 has been reported7 .
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Our results suggest that ongoing anti-contagion policies have already substantially reduced the number of COVID-19 infections observed in the world today (Figure 4). Our central estimates suggest that there would be roughly 37 million more cumulative confirmed cases (corresponding to 285 million more total infections, including the confirmed cases) in China, 11.5 million more confirmed cases in South Korea (38 million total infections), 2.1 million more confirmed cases in Italy (49 million total infections), 5 million more confirmed cases in Iran (54 million total infections), 1.4 million more confirmed cases in France (45 million total infections),
and 4.8 million more confirmed cases (60 million total infections) in the US
had these countries never enacted any anti-contagion policies since the start of the pandemic.
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Discussion Our empirical results indicate that large-scale anti-contagion policies are slowing the COVID-19 pandemic. Because infection rates in the countries we study would have initially followed rapid exponential growth had no policies been applied, our results suggest that these policies have provided large health benefits. For example, we estimate that there would be roughly 465 × the observed number of confirmed cases in China, 17 × in Italy, and 14 × in the US by the end of our sample if large-scale anti-contagion policies had not been deployed. Consistent with process-based simulations of COVID-19 infections2,4,8,9,22,26, our analysis of existing policies indicates that seemingly small delays in policy deployment likely produced dramatically different health outcomes...
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Our results suggest that ongoing anti-contagion policies have already substantially reduced the number of COVID-19 infections observed in the world today (Figure 4). Our central estimates suggest that there would be roughly 37 million more cumulative confirmed cases (corresponding to 285 million more total infections, including the confirmed cases) in China, 11.5 million more confirmed cases in South Korea (38 million total infections), 2.1 million more confirmed cases in Italy (49 million total infections), 5 million more confirmed cases in Iran (54 million total infections), 1.4 million more confirmed cases in France (45 million total infections),
and 4.8 million more confirmed cases (60 million total infections) in the US
had these countries never enacted any anti-contagion policies since the start of the pandemic.
Community Use Of Face Masks And COVID-19: Evidence From A Natural Experiment Of State Mandates In The US
On April 3, 2020, the Centers for Disease Control and Prevention (CDC) issued new guidance advising all individuals to wear cloth facial covers in public areas where close contact with others is unavoidable, citing new evidence on virus transmission from asymptomatic or pre-symptomatic individuals.12
Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study
Aravinthan Varatharaj, MRCP Naomi Thomas, MRCPCH Mark A Ellul, MRCP Nicholas W S Davies, PhD Thomas A Pollak, MRCP Elizabeth L Tenorio, PhD Mustafa Sultan Ava Easton, PhD Prof Gerome Breen, PhD Michael Zandi, PhD Prof Jonathan P Coles, PhD Hadi Manji, FRCP Prof Rustam Al-Shahi Salman, PhD Prof David K Menon, PhD Timothy R Nicholson, PhD Laura A Benjamin, PhD Prof Alan Carson, PhD Prof Craig Smith, MD Prof Martin R Turner, PhD Prof Tom Solomon, PhD Rachel Kneen, MRCPCH Prof Sarah L Pett, PhD Ian Galea, PhD * Rhys H Thomas, PhD * Benedict D Michael, PhD * on behalf of theCoroNerve Study Group †
Published:June 25, 2020DOI:https://doi.org/10.1016/S2215-0366(20)30287-X ;
Summary Background
Concerns regarding potential neurological complications of COVID-19 are being increasingly reported, primarily in small series. Larger studies have been limited by both geography and specialty. Comprehensive characterisation of clinical syndromes is crucial to allow rational selection and evaluation of potential therapies. The aim of this study was to investigate the breadth of complications of COVID-19 across the UK that affected the brain.
Methods
During the exponential phase of the pandemic, we developed an online network of secure rapid-response case report notification portals across the spectrum of major UK neuroscience bodies, comprising the Association of British Neurologists (ABN), the British Association of Stroke Physicians (BASP), and the Royal College of Psychiatrists (RCPsych), and representing neurology, stroke, psychiatry, and intensive care. Broad clinical syndromes associated with COVID-19 were classified as a cerebrovascular event (defined as an acute ischaemic, haemorrhagic, or thrombotic vascular event involving the brain parenchyma or subarachnoid space), altered mental status (defined as an acute alteration in personality, behaviour, cognition, or consciousness), peripheral neurology (defined as involving nerve roots, peripheral nerves, neuromuscular junction, or muscle), or other (with free text boxes for those not meeting these syndromic presentations). Physicians were encouraged to report cases prospectively and we permitted recent cases to be notified retrospectively when assigned a confirmed date of admission or initial clinical assessment, allowing identification of cases that occurred before notification portals were available. Data collected were compared with the geographical, demographic, and temporal presentation of overall cases of COVID-19 as reported by UK Government public health bodies.
Findings
The ABN portal was launched on April 2, 2020, the BASP portal on April 3, 2020, and the RCPsych portal on April 21, 2020. Data lock for this report was on April 26, 2020. During this period, the platforms received notification of 153 unique cases that met the clinical case definitions by clinicians in the UK, with an exponential growth in reported cases that was similar to overall COVID-19 data from UK Government public health bodies. Median patient age was 71 years (range 23–94; IQR 58–79). Complete clinical datasets were available for 125 (82%) of 153 patients. 77 (62%) of 125 patients presented with a cerebrovascular event, of whom 57 (74%) had an ischaemic stroke, nine (12%) an intracerebral haemorrhage, and one (1%) CNS vasculitis. 39 (31%) of 125 patients presented with altered mental status, comprising nine (23%) patients with unspecified encephalopathy and seven (18%) patients with encephalitis. The remaining 23 (59%) patients with altered mental status fulfilled the clinical case definitions for psychiatric diagnoses as classified by the notifying psychiatrist or neuropsychiatrist, and 21 (92%) of these were new diagnoses. Ten (43%) of 23 patients with neuropsychiatric disorders had new-onset psychosis, six (26%) had a neurocognitive (dementia-like) syndrome, and four (17%) had an affective disorder. 18 (49%) of 37 patients with altered mental status were younger than 60 years and 19 (51%) were older than 60 years, whereas 13 (18%) of 74 patients with cerebrovascular events were younger than 60 years versus 61 (82%) patients older than 60 years.
Interpretation
To our knowledge, this is the first nationwide, cross-specialty surveillance study of acute neurological and psychiatric complications of COVID-19. Altered mental status was the second most common presentation, comprising encephalopathy or encephalitis and primary psychiatric diagnoses, often occurring in younger patients. This study provides valuable and timely data that are urgently needed by clinicians, researchers, and funders to inform immediate steps in COVID-19 neuroscience research and health policy.
Funding
None.
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Discussion
To our knowledge, this is the first systematic, nationwide UK surveillance study of the breadth of acute complications of COVID-19 in the nervous system, undertaken through rapid mobilisation of UK professional bodies representing neurology, stroke or acute medicine, psychiatry, and intensive care. Cases notified by the professional membership of these bodies were obtained from across the UK, and an exponential rise in cases of neurological and psychiatric complications of COVID-19 occurred during the exponential rise in overall COVID-19 cases reported by UK Government public health bodies.
Future studies on neurological complications of COVID-19, particularly those assessing genetic and associated risk factors, would benefit from obtaining notification of all cases of infection admitted to every hospital as a denominator, or a cohort of COVID-19 patients without neurological or psychiatric complications as a control group. However, given the time pressure on busy clinical teams during the pandemic, we focused our notification structure on patients with neurological or psychiatric complications of infection. Cases were reported from physicians who spanned various specialties, and almost all cases met the case definition of confirmed SARS-CoV-2 infection.
Cerebrovascular events in patients with COVID-19, which have been well described elsewhere,
,
were also identified as a major group within our cohort. However, we identified a large proportion of cases of acute alteration in mental status, comprising neurological syndromic diagnoses such as encephalopathy and encephalitis and primary psychiatric syndromic diagnoses, such as psychosis. Although cerebrovascular events and altered mental status were identified across all age groups, our cohort confirms that cerebrovascular events predominate in older patients; however, these early data identify that acute alterations in mental status were disproportionately overrepresented in younger patients in our cohort. Our rates of neurological and psychiatric complications of COVID-19 cannot be extrapolated to mildly affected patients or patients with asymptomatic infection, especially those in the community, but give a broad national perspective on complications severe enough to require hospitalisation.
Our approach to case ascertainment has the potential for reporting bias and requires validation through detailed prospective clinicoepidemiological data collection. Plans for such studies should be developed in advance of future pandemics, so that they can be mobilised early during disease spread. A more engaged professional membership or those more used to submitting data to surveillance studies through this approach could potentially be overrepresented in our results. However, this study was the first major national investigation to use a data surveillance approach for clinicians, who notified a large proportion of our cohort (ie, BASP and RCPsych). Additionally, the present study included a priori considerations to determine the strength of the evidence for SARS-CoV-2 infection, and data collection was informed by clear clinical case definitions. Moreover, in this cohort, we conclude that this study is unlikely to have had systematic over ascertainment bias for psychiatric or neuropsychiatric presentations. 41% of cases were reported by stroke physicians, and the RCPsych web portal was launched 18 days later than the other neurological, stroke, and intensive care unit or more general portals, yet we observed a large number of psychiatric or neuropsychiatric notifications. Indeed, as many patients with COVID-19 are managed in intensive care units with sedative and paralytic medications, which can both mask and contribute to iatrogenic complications, our cohort might underrepresent the rate of neurological or psychiatric symptoms.
Since we specifically identified moderate to severe complications of COVID-19 as they were reported for inpatient cases by neurologists and psychiatrists, our cohort might underrepresent patients with milder outpatient symptoms, such as reduced taste or smell. Future hypothesis testing studies building on our findings to infer causal relationships between infection and neurological or neuropsychiatric presentations should adhere to basic principles, such as the criteria for causation outlined by Bradford Hill as they pertain to pandemic respiratory infection and effects on the brain.
Many cerebrovascular events were identified in our study, as reported in previous cohorts and case reports of acute COVID-19 complications.
,
,
The pathophysiological mechanisms that underlie cerebrovascular events in COVID-19 require further study, but there is a potential biological rationale for a vasculopathy, with a report of SARS-CoV-2 endothelitis in organs outside the cerebral vasculature
and cerebrovascular events,
in addition to coagulopathy, along with conventional stroke risk during sepsis.
,
,
Comprehensive studies with clear control groups, including patients hospitalised with COVID-19 but without cerebrovascular events and patients with cerebrovascular events but who do not have COVID-19, are required to address this issue.
Confirmation of the link between COVID-19 and new acute psychiatric or neuropsychiatric complications in younger patients will require detailed prospective longitudinal studies. Understanding this association will require systematic participant evaluation, characterisation of immune host responses, exploration of genetic associations, and comparison with appropriate controls (including patients hospitalised with COVID-19 who do not have acute neuropsychiatric features).
Altered mental status is common in patients admitted to hospital with severe infection, especially in those requiring intensive care management. However, this symptom typically predominates in older groups, and might reflect an unmasking of latent neurocognitive degenerative disease or multiple medical comorbidities, often in association with sepsis, hypoxia, and the requirement for polypharmacy and sedative medications. In this study, we observed a disproportionate number of neuropsychiatric presentations in younger patients and a predominance of cerebrovascular complications in older patients, which might reflect the state of health of the cerebral vasculature and associated risk factors, exacerbated by critical illness in older patients.
The large number of patients with altered mental status might reflect increased access to neuropsychiatry or psychiatry review for younger patients, and increased attribution of altered mental status to delirium in older patients. Nevertheless, the increased recognition of acute altered mental status in patients hospitalised with COVID-19 warrants study. The exclusion of iatrogenic factors, such as sedatives and antipsychotics, should be quantified in future modelling studies. In our study, although most psychiatric diagnoses were determined as new by the notifying psychiatrist or neuropsychiatrist, we cannot exclude the possibility that these were undiagnosed before the patient developed COVID-19.
Our study population represents a snapshot of hospitalised patients with acute neurological or psychiatric complications associated with COVID-19. Larger, ideally prospective, studies should identify the broader cohort of COVID-19 patients both in and outside hospitals, with capture–recapture analysis and health record linkage to determine clearer estimates of the prevalence of these complications and individuals at risk. Additionally, community studies are required to identify those at risk of both COVID-19 and neurological or psychiatric complications, although this strategy will require widespread serological testing.
The importance of data sharing is increasingly recognised as fundamental to facilitate rapidly responsive clinical research and is particularly crucial during an international emergency, such as the SARS-CoV-2 pandemic. The CoroNerve Study Group has been made possible by open collaboration between several UK institutions. We anticipate added value of sharing data more widely, across European and global partners, particularly in low-income and middle-income countries. The Brain Infections Global COVID-Neuro Network is supporting data collection in such countries through freely available case record forms.
Wide collaboration is likely to be even more important for characterising rarer or novel COVID-19-associated neurological syndromes. These enriched populations that reflect less common, but nevertheless severe, disease must be studied in close collaboration with larger surveillance efforts, such as the ISARIC Clinical Characterisation Protocol, to identify at-risk groups, determine the strength of relative risk factors, and have adequate controls for mechanistic studies.
Our nationwide, clinician-reported cohort approach provides valuable and timely information that is urgently needed by clinicians, researchers, and funders to inform the immediate next steps in COVID-19 neuroscience-related research and health policy planning. These national data begin to characterise the spectrum of neurological and neuropsychiatric complications that need to be addressed. This multidisciplinary, coordinated approach should be emulated in detailed national mechanistic studies of COVID-19 and the brain, to distinguish the role of the virus and the host inflammatory response versus the broader socioeconomic effects of the pandemic.
Contributors
AV and BDM drafted the initial manuscript and the document was edited and approved by all coauthors.
Declaration of interests
Original Investigation
June 8, 2020
JAMA. Published online June 8, 2020. doi:10.1001/jama.2020.10369
Clinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2
Elizabeth Whittaker, MD1,2; Alasdair Bamford, MD3,4; Julia Kenny, MD5,6; et al
Key Points Question What are the clinical and laboratory characteristics of critically ill children who developed an inflammatory multisystem syndrome during the coronavirus disease 2019 pandemic?
Findings This case series included 58 hospitalized children, a subset of whom required intensive care, and met definitional criteria for pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (PIMS-TS), including fever, inflammation, and organ dysfunction. Of these children, all had fever and nonspecific symptoms, such as abdominal pain (31 [53%]), rash (30 [52%]), and conjunctival injection (26 [45%]); 29 (50%) developed shock and required inotropic support or fluid resuscitation; 13 (22%) met diagnostic criteria for Kawasaki disease; and 8 (14%) had coronary artery dilatation or aneurysms. Some clinical and laboratory characteristics had important differences compared with Kawasaki disease, Kawasaki disease shock syndrome, and toxic shock syndrome.
Meaning These findings help characterize the clinical features of hospitalized, seriously ill children with PIMS-TS and provide insights into this apparently novel syndrome.
Abstract Importance In communities with high rates of coronavirus disease 2019, reports have emerged of children with an unusual syndrome of fever and inflammation.
Objectives To describe the clinical and laboratory characteristics of hospitalized children who met criteria for the pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PIMS-TS) and compare these characteristics with other pediatric inflammatory disorders.
Design, Setting, and Participants Case series of 58 children from 8 hospitals in England admitted between March 23 and May 16, 2020, with persistent fever and laboratory evidence of inflammation meeting published definitions for PIMS-TS. The final date of follow-up was May 22, 2020. Clinical and laboratory characteristics were abstracted by medical record review, and were compared with clinical characteristics of patients with Kawasaki disease (KD) (n = 1132), KD shock syndrome (n = 45), and toxic shock syndrome (n = 37) who had been admitted to hospitals in Europe and the US from 2002 to 2019.
Exposures Signs and symptoms and laboratory and imaging findings of children who met definitional criteria for PIMS-TS from the UK, the US, and World Health Organization.
Main Outcomes and Measures Clinical, laboratory, and imaging characteristics of children meeting definitional criteria for PIMS-TS, and comparison with the characteristics of other pediatric inflammatory disorders.
Results Fifty-eight children (median age, 9 years [interquartile range {IQR}, 5.7-14]; 33 girls [57%]) were identified who met the criteria for PIMS-TS. Results from SARS-CoV-2 polymerase chain reaction tests were positive in 15 of 58 patients (26%) and SARS-CoV-2 IgG test results were positive in 40 of 46 (87%). In total, 45 of 58 patients (78%) had evidence of current or prior SARS-CoV-2 infection. All children presented with fever and nonspecific symptoms, including vomiting (26/58 [45%]), abdominal pain (31/58 [53%]), and diarrhea (30/58 [52%]). Rash was present in 30 of 58 (52%), and conjunctival injection in 26 of 58 (45%) cases. Laboratory evaluation was consistent with marked inflammation, for example, C-reactive protein (229 mg/L [IQR, 156-338], assessed in 58 of 58) and ferritin (610 μg/L [IQR, 359-1280], assessed in 53 of 58). Of the 58 children, 29 developed shock (with biochemical evidence of myocardial dysfunction) and required inotropic support and fluid resuscitation (including 23/29 [79%] who received mechanical ventilation); 13 met the American Heart Association definition of KD, and 23 had fever and inflammation without features of shock or KD. Eight patients (14%) developed coronary artery dilatation or aneurysm. Comparison of PIMS-TS with KD and with KD shock syndrome showed differences in clinical and laboratory features, including older age (median age, 9 years [IQR, 5.7-14] vs 2.7 years [IQR, 1.4-4.7] and 3.8 years [IQR, 0.2-18], respectively), and greater elevation of inflammatory markers such as C-reactive protein (median, 229 mg/L [IQR 156-338] vs 67 mg/L [IQR, 40-150 mg/L] and 193 mg/L [IQR, 83-237], respectively).
Conclusions and Relevance In this case series of hospitalized children who met criteria for PIMS-TS, there was a wide spectrum of presenting signs and symptoms and disease severity, ranging from fever and inflammation to myocardial injury, shock, and development of coronary artery aneurysms. The comparison with patients with KD and KD shock syndrome provides insights into this syndrome, and suggests this disorder differs from other pediatric inflammatory entities.
Snip...
Since the first reports of an unusual inflammatory illness in children that emerged in the months following the onset of COVID-19, there have been additional reports from many countries of children with fever and inflammation, for which no cause could be identified, first in health alerts and web exchanges between professional groups, and then in case reports and small case series in rapid publications.2-4 As these cases have emerged in temporal association with the pandemic, a link with SARS-CoV-2 is likely.
COVID-19 AND CHILDREN
Published Online May 6, 2020 https://doi.org/10.1016/ S0140-6736(20)31094-1
Hyperinflammatory shock in children during COVID-19 pandemic
South Thames Retrieval Service in London, UK, provides paediatric intensive care support and retrieval to 2 million children in South East England. During a period of 10 days in mid-April, 2020, we noted an unprecedented cluster of eight children with hyperinflammatory shock, showing features similar to atypical Kawasaki disease, Kawasaki disease shock syndrome,1 or toxic shock syndrome (typical number is one or two children per week). This case cluster formed the basis of a national alert. All children were previously fit and well. Six of the children were of AfroCaribbean descent, and five of the children were boys. All children except one were well above the 75th centile for weight. Four children had known family exposure to coronavirus disease 2019 (COVID-19). Demographics, clinical findings, imaging findings, treatment, and outcome for this cluster of eight children are shown in the table.
Clinical presentations were similar, with unrelenting fever (38–40°C), variable rash, conjunctivitis, peripheral oedema, and generalised extremity pain with significant gastrointestinal symptoms. All progressed to warm, vasoplegic shock, refractory to volume resuscitation and eventually requiring noradrenaline and milrinone for haemodynamic support. Most of the children had no significant respiratory involvement, although seven of the children required mechanical ventilation for cardiovascular stabilisation. Other notable features (besides persistent fever and rash) included development of small pleural, pericardial, and ascitic effusions, suggestive of a diffuse inflammatory process.
All children tested negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on bronchoalveolar lavage or nasopharyngeal aspirates. Despite being critically unwell, with laboratory evidence of infection or inflammation3 including elevated concentrations of C-reactive protein, procalcitonin, ferritin, triglycerides, and D-dimers, no pathological organism was identified in seven of the children. Adenovirus and enterovirus were isolated in one child.
Baseline electrocardiograms were non-specific; however, a common echocardiographic finding was echobright coronary vessels (appendix), which progressed to giant coronary aneurysm in one patient within a week of discharge from paediatric intensive care (appendix). One child developed arrhythmia with refractory shock, requiring extracorporeal life support, and died from a large cerebrovascular infarct. The myocardial involvement2 in this syndrome is evidenced by very elevated cardiac enzymes during the course of illness.
All children were given intravenous immunoglobulin (2 g/kg) in the first 24 h, and antibiotic cover including ceftriaxone and clindamycin. Subsequently, six children have been given 50 mg/kg aspirin. All of the children were discharged from PICU after 4–6 days. Since discharge, two of the children have tested positive for SARSCoV-2 (including the child who died, in whom SARS-CoV-2 was detected post mortem). All children are receiving ongoing surveillance for coronary abnormalities.
We suggest that this clinical picture represents 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).
The intention of this Correspondence is to bring this subset of children to the attention of the wider paediatric community and to optimise early recognition and management. As this Correspondence goes to press, 1 week after the initial submission, the Evelina London Children’s Hospital paediatric intensive care unit has managed more than 20 children with similar clinical presentation, the first ten of whom tested positive for antibody (including the original eight children in the cohort described above).
We declare no competing interests.
*Shelley Riphagen, Xabier Gomez, Carmen Gonzalez-Martinez, Nick Wilkinson, Paraskevi Theocharis shelley.riphagen@gstt.nhs.uk
South Thames Retrieval Service for Children, Evelina London Children’s Hospital Paediatric Intensive Care Unit, London SE1 7EH, UK (SR, XG); and Evelina London Children’s Hospital, London, UK (CG-M, NW, PT)
2 New York Boys Die Of Multi-System Inflammatory Syndrome Affecting Children Amid Coronavirus Pandemic
May 8, 2020 at 11:41 pmFiled Under:Coronavirus, COVID-19, Health, Jessica Layton, Local TV, multi-symptom inflammatory syndrome, New York, Tony Aiello, Valhalla, Westchester County
VALHALLA, N.Y. (CBSNewYork) — A Westchester County boy has died after coming down with an illness affecting dozens of children in New York State.
The 7-year-old boy died late last week at Maria Fareri Children’s Hospital in Valhalla. Dr. Michael Gewitz said he suffered neurological complications from what is now called pediatric multi-system inflammatory syndrome.
Health officials said there have been 73 suspected cases of the illness statewide and investigators are doing a deep dive into the circumstances.
Gov. Andrew Cuomo shared an update Friday, announcing the death of a 5-year-old boy, who CBS2 later confirmed died at Mount Sinai Kravis Children’s Hospital.
“Right now we have a new issue that we’re looking at, which is something we’re just investigating now, but, while rare, we’re seeing some cases where children affected with the COVID virus can become ill with symptoms similar to the Kawasaki disease or Toxic Shock-like syndrome that literally causes inflammation in their blood vessels,” Cuomo said. “This past Thursday, a 5-year-old boy passed away from COVID-related complications, and the State Department of Health is investigating several other cases that presents similar circumstances.”
The hospital said in part, “We must emphasize that based on what we know thus far, it appears to be a very rare condition.”
WATCH: Gov. Cuomo Warns About New Disease Affecting Children Amid Pandemic
It’s still unclear exactly how the syndrome relates to the coronavirus.
The Westchester boy tested positive for COVID-19 antibodies, meaning he was previously infected and had recovered, CBS2’s Tony Aiello reported.
“And we know that in some of the households parents or grandparents or others were diagnosed with COVID and were actually on the record being positive, and apparently the children did not develop symptoms until two to four days before presenting to the hospital for treatment,” said Dr. Dial Hewlett of the Westchester County Department of Health.
“This is very serious. The disease can be fatal, and we want to make sure everyone in Westchester County is aware to be on the lookout for symptoms that may lead to this,” County Executive George Latimer added.
Web Extra: Health Advisory On Pediatric Multi-System Inflammatory Syndrome
Seek care immediately if a child has:
Prolonged fever (more than 5 days)
Difficulty feeding (infants) or is too sick to drink fluids
Severe abdominal pain, diarrhea, or vomiting
Change in skin color – becoming pale, patchy, and/or blue Trouble breathing or is breathing very quickly
Racing heart or chest pain
Decreased amount or frequency of urine Lethargy, irritability, or confusion
“So this is every parent’s nightmare, right? That your child may actually be affected by this virus. But it’s something we have to consider seriously now,” Gov. Cuomo said.
In New Jersey, a 4-year-old child with underlying health issues has also died. It’s unclear if he was affected by the inflammatory syndrome, but there are a handful of other suspected cases in Garden State kids.
“It’s a virus that’s proving to be extremely challenging at every level,” Gov. Phil Murphy said.
Dr. Gewitz said while COVID-19 is likely to infect a large number of children, “most of whom, at least many, are totally asymptomatic. This particular complication is relatively infrequent, unusual.”
SARS-CoV-2 Infection in Children
Of the 1391 children assessed and tested from January 28 through February 26, 2020, a total of 171 (12.3%) were confirmed to have SARS-CoV-2 infection. Demographic data and clinical features are summarized in Table 1. (Details of the laboratory and radiologic findings are provided in the Supplementary Appendix, available with the full text of this letter at NEJM.org.) The median age of the infected children was 6.7 years. Fever was present in 41.5% of the children at any time during the illness. Other common signs and symptoms included cough and pharyngeal erythema. A total of 27 patients (15.8%) did not have any symptoms of infection or radiologic features of pneumonia. A total of 12 patients had radiologic features of pneumonia but did not have any symptoms of infection. During the course of hospitalization, 3 patients required intensive care support and invasive mechanical ventilation; all had coexisting conditions (hydronephrosis, leukemia [for which the patient was receiving maintenance chemotherapy], and intussusception). Lymphopenia (lymphocyte count, <1 .2="" 10-month-old="" 149="" 2020="" 21="" 4="" 6="" 8="" a="" admission.="" after="" and="" as="" been="" bilateral="" child="" common="" condition="" death.="" died="" discharged="" div="" failure="" finding="" from="" general="" ground-glass="" had="" have="" hospital.="" in="" intussusception="" liter="" march="" most="" multiorgan="" of="" one="" opacity="" patients="" per="" present="" radiologic="" stable="" the="" there="" total="" wards="" was="" weeks="" were="" with="">
This report describes a spectrum of illness from SARS-CoV-2 infection in children. In contrast with infected adults, most infected children appear to have a milder clinical course. Asymptomatic infections were not uncommon.2 Determination of the transmission potential of these asymptomatic patients is important for guiding the development of measures to control the ongoing pandemic.
Two COVID-19 infected children, aged 12 and 13, die in Belgium and UK
By Alasdair Sandford with AFP, AP • last updated: 01/04/2020
A health worker in the intensive care ward observes a COVID-19 patient at a hospital in Belgium, March 27, 2020. (AP Photo/Francisco Seco, File)
A 12-year-old girl in Belgium and a 13-year old boy in the UK infected with the novel coronavirus have died, authorities said.
They are believed to be the youngest victims of the disease in their respective countries.
The 12-year-old girl's death was announced during the daily news conference given by Belgium's health service, at the end of its regular update on casualty figures and hospitalisations.
“It's an emotionally difficult moment because it involves a child, and it has also upset the medical and scientific community,” said spokesman Dr Emmanuel André, visibly upset.
"We are thinking of her family and friends. It's a very rare event, but one which devastates us."
Another spokesman added that the child had had a fever for three days and had tested positive for the coronavirus. No other details were given of the girl's background.
Until now the youngest person to die from the virus in Belgium was a 30-year-old female nurse, according to Belgian media.
Just a few hours later, London's King's College Hospital announced that a 13-year-old COVID-19 patient had also died.
"Sadly, a 13-year old boy who tested positive for COVID-19 has passed away, and our thoughts and condolences are with the family at this time," a Trust spokesperson said in a statement.
"The death has been referred to the Coroner," it added.
An appeal posted on the GoFunMe crowdfunding platform by Madinah College, named him as Ismail and said that he didn't have "any pre-existing health conditions.
"Sadly he died without any family members close by due to the highly infectious nature of COVID-19," it added.
Ismail is believed the be the youngest victim of the disease in the UK.
Last week French authorities said a 16-year-old girl had died at a children's hospital in Paris. The death of the teenager, identified as Julie A. and described as otherwise healthy, has provoked strong emotions in France.
Coronavirus in France: healthy 16 year-old dies of COVID-19
Deaths from COVID-19 among people so young are exceptional. Health authorities have said previously that serious cases of the illness -- although predominant in older and more vulnerable age groups -- can occur in adults of any age.
Last weekend the US state of Illinois announced the death of an infant under one year old who had tested positive for coronavirus. The cause of death was being investigated. Medical reports on cases in China have documented the death of a 10-month-old baby and a 14-year-old boy.
A recent US study by the Centers for Disease Control and Prevention (CDC) of 2,500 patients found no cases of deaths among people aged under 19. But it did find that people of all ages were liable to become seriously ill: more than a third of those hospitalised were aged between 20 and 54.
Coronavirus in Europe: Latest numbers on COVID-19 cases and deaths
The Belgian girl's death was included among the latest national figures released on Tuesday, confirming nearly 200 more deaths since the previous update. More than 700 people in the country have died from coronavirus since the outbreak began.
Hospitals in three regions have been particularly badly affected, the authorities say -- around Brussels, in Limburg in eastern Flanders, and in Hainaut in Wallonia to the west.
With 12,775 confirmed COVID-19 cases as of Tuesday, Belgium has the 10th highest number of infections among countries worldwide, according to data compiled by the US Johns Hopkins University Coronavirus Resource Center.
June 15, 2020
Gary L. Disbrow Ph.D. Deputy Assistant Secretary Director, Medical Countermeasure Programs Biomedical Advanced Research and Development Authority (BARDA) Office of Assistant Secretary for Preparedness and Response (ASPR) U.S. Department of Health and Human Services (HHS) 330 Independence Ave, S.W., Room 640G Washington, D.C. 20201
Dear Dr. Disbrow:
This letter is in response to your request, dated today, that the Food and Drug Administration (FDA) revoke the Emergency Use Authorization (EUA) for emergency use of oral formulations of chloroquine phosphate (CQ) and hydroxychloroquine sulfate (HCQ) to be distributed from the Strategic National Stockpile (SNS) issued on March 28, 2020. Like BARDA’s earlier request to FDA to issue the EUA, BARDA’s request to revoke the EUA is part of a collaborative, USGinteragency effort to rapidly respond to this continuously evolving public health emergency. Today’s request to revoke is based on new information, including clinical trial data results, that have led BARDA to conclude that this drug may not be effective to treat COVID-19 [Coronavirus Disease 2019] and that the drug’s potential benefits for such use do not outweigh its known and potential risks.
The authorization of a product for emergency use under section 564 of the Federal Food, Drug, and Cosmetic Act (the Act) (21 U.S.C. 360bbb-3) may, pursuant to section 564(g)(2) of the Act, be revised or revoked when the criteria under section 564(b)(1) of the Act no longer exist, the criteria under section 564(c) of the Act for issuance of such authorization are no longer met, or other circumstances make such revision or revocation appropriate to protect the public health or safety.
FDA has determined that the criteria under section 564(c) of the Act for issuance of the EUA referenced above are no longer met. Under section 564(c)(2) of the Act, an EUA may be issued only if FDA concludes “that, based on the totality of scientific evidence available to the Secretary, including data from adequate and well-controlled clinical trials, if available, it is reasonable to believe that: (A) the product may be effective in diagnosing, treating, or preventing—(i) such disease or condition [….]; and (B) the known and potential benefits of the product, when used to diagnose, prevent, or treat such disease or condition, outweigh the known and potential risks of the product […].”
As explained in the attached memorandum, based on a review of new information and a reevaluation of information available at the time the EUA was issued, FDA now concludes that these criteria are no longer met. The bases for this decision include the following:
FDA REVOKES Emergency Use Authorization (EUA) for emergency use of oral formulations of chloroquine phosphate (CQ) and hydroxychloroquine sulfate (HCQ)
As explained in the attached memorandum, based on a review of new information and a reevaluation of information available at the time the EUA was issued, FDA now concludes that these criteria are no longer met. The bases for this decision include the following:
THURSDAY, JUNE 11, 2020
The effect of large-scale anti-contagion policies on the COVID-19 pandemic
SUNDAY, MAY 17, 2020
CORONAVIRUS IN TEXAS, More than 700 new cases of coronavirus meatpacking plants Amarillo region, 11 county deaths connected to Long Term Care Facility at Texas City
CORONAVIRUS IN TEXAS
SATURDAY, MAY 9, 2020
Covid-19 Mortality, Crunching the Numbers, Children, The Jungle 1906 to 2020
REPORT
Susceptibility of ferrets, cats, dogs, and other domesticated animals to SARS–coronavirus 2
View ORCID ProfileJianzhong Shi1,*, View ORCID ProfileZhiyuan Wen1,*, View ORCID ProfileGongxun Zhong1,*, View ORCID ProfileHuanliang Yang1,*, View ORCID ProfileChong Wang1,*, View ORCID ProfileBaoying Huang2,*, Renqiang Liu1, Xijun He3, Lei Shuai1, Ziruo Sun1, Yubo Zhao1, View ORCID ProfilePeipei Liu2, Libin Liang1, Pengfei Cui1, Jinliang Wang1, View ORCID ProfileXianfeng Zhang3, Yuntao Guan3, View ORCID ProfileWenjie Tan2, View ORCID ProfileGuizhen Wu2,†, View ORCID ProfileHualan Chen1,†, View ORCID ProfileZhigao Bu1,3,† See all authors and affiliations
Science 29 May 2020: Vol. 368, Issue 6494, pp. 1016-1020 DOI: 10.1126/science.abb7015 Article Figures & Data Info & Metrics eLetters PDF Alternative hosts and model animals The severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2) pandemic may have originated in bats, but how it made its way into humans is unknown. Because of its zoonotic origins, SARS-CoV-2 is unlikely to exclusively infect humans, so it would be valuable to have an animal model for drug and vaccine development. Shi et al. tested ferrets, as well as livestock and companion animals of humans, for their susceptibility to SARS-CoV-2 (see the Perspective by Lakdawala and Menachery). The authors found that SARS-CoV-2 infects the upper respiratory tracts of ferrets but is poorly transmissible between individuals. In cats, the virus replicated in the nose and throat and caused inflammatory pathology deeper in the respiratory tract, and airborne transmission did occur between pairs of cats. Dogs appeared not to support viral replication well and had low susceptibility to the virus, and pigs, chickens, and ducks were not susceptible to SARS-CoV-2.
Science, this issue p. 1016; see also p. 942
Abstract
Severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2) causes the infectious disease COVID-19 (coronavirus disease 2019), which was first reported in Wuhan, China, in December 2019. Despite extensive efforts to control the disease, COVID-19 has now spread to more than 100 countries and caused a global pandemic. SARS-CoV-2 is thought to have originated in bats; however, the intermediate animal sources of the virus are unknown. In this study, we investigated the susceptibility of ferrets and animals in close contact with humans to SARS-CoV-2. We found that SARS-CoV-2 replicates poorly in dogs, pigs, chickens, and ducks, but ferrets and cats are permissive to infection. Additionally, cats are susceptible to airborne transmission. Our study provides insights into the animal models for SARS-CoV-2 and animal management for COVID-19 control.
snip...
In summary, we found that ferrets and cats are highly susceptible to SARS-CoV-2; dogs have low susceptibility; and pigs, chickens, and ducks are not susceptible to the virus. Unlike influenza viruses and the other SARS-coronavirus known to infect humans (SARS-CoV-1), which replicate in both the upper and lower respiratory tract of ferrets (20, 22–24, 26, 27), SARS-CoV-2 replicates only in the nasal turbinate, soft palate, and tonsils of ferrets. SARS-CoV-2 may also replicate in the digestive tract, as viral RNA was detected in the rectal swabs of the virus-infected ferrets, but virus was not detected in lung lobes, even after the ferrets were intratracheally inoculated with the virus. It remains unclear whether the virus causes more severe disease in male ferrets than in female ferrets, as has been observed among humans (13, 28).
Several studies have reported that SARS-CoV-2 uses angiotensin-converting enzyme 2 (ACE2) as its receptor to enter cells (3, 29–31). ACE2 is mainly expressed in type II pneumocytes and serous epithelial cells of tracheo-bronchial submucosal glands in ferrets (25). Ferrets and cats differ by only two amino acids in the SARS-CoV-2 spike-contacting regions of ACE2 (table S1); therefore, the underlying mechanism that prevents the replication of SARS-CoV-2 in the lower respiratory tract of ferrets remains to be investigated. The fact that SARS-CoV-2 replicates efficiently in the upper respiratory tract of ferrets makes them a candidate animal model for evaluating the efficacy of antiviral drugs or vaccines against COVID-19.
The cats we used in this study were outbred and were susceptible to SARS-CoV-2, which replicated efficiently and was transmissible to naïve cats. Cats in Wuhan have been reported to be seropositive for SARS-CoV-2 (32). Surveillance for SARS-CoV-2 in cats should be considered as an adjunct to elimination of COVID-19 in humans.
SUNDAY, MAY 17, 2020
CORONAVIRUS IN TEXAS, More than 700 new cases of coronavirus meatpacking plants Amarillo region, 11 county deaths connected to Long Term Care Facility at Texas City
We’re going to win so much, you’re going to be so sick and tired of winning, you’re going to come to me and go ‘Please, please, we can’t win anymore.’ You’ve heard this one. You’ll say ‘Please, Mr. President, we beg you sir, we don’t want to win anymore. It’s too much. It’s not fair to everybody else.’” Trump said.
Trump gop maga, “get back to work now” like leading sheep to slaughter...tss
WEDNESDAY, APRIL 29, 2020
President Donald J. Trump signed an Executive Order to keep meat and poultry processing facilities open during the COVID-19 national emergency
SATURDAY, APRIL 18, 2020
Coronavirus at Smithfield pork plant: The untold story of America's biggest outbreak
REPORT
Susceptibility of ferrets, cats, dogs, and other domesticated animals to SARS–coronavirus 2
View ORCID ProfileJianzhong Shi1,*, View ORCID ProfileZhiyuan Wen1,*, View ORCID ProfileGongxun Zhong1,*, View ORCID ProfileHuanliang Yang1,*, View ORCID ProfileChong Wang1,*, View ORCID ProfileBaoying Huang2,*, Renqiang Liu1, Xijun He3, Lei Shuai1, Ziruo Sun1, Yubo Zhao1, View ORCID ProfilePeipei Liu2, Libin Liang1, Pengfei Cui1, Jinliang Wang1, View ORCID ProfileXianfeng Zhang3, Yuntao Guan3, View ORCID ProfileWenjie Tan2, View ORCID ProfileGuizhen Wu2,†, View ORCID ProfileHualan Chen1,†, View ORCID ProfileZhigao Bu1,3,† See all authors and affiliations
Science 29 May 2020: Vol. 368, Issue 6494, pp. 1016-1020 DOI: 10.1126/science.abb7015 Article Figures & Data Info & Metrics eLetters PDF Alternative hosts and model animals The severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2) pandemic may have originated in bats, but how it made its way into humans is unknown. Because of its zoonotic origins, SARS-CoV-2 is unlikely to exclusively infect humans, so it would be valuable to have an animal model for drug and vaccine development. Shi et al. tested ferrets, as well as livestock and companion animals of humans, for their susceptibility to SARS-CoV-2 (see the Perspective by Lakdawala and Menachery). The authors found that SARS-CoV-2 infects the upper respiratory tracts of ferrets but is poorly transmissible between individuals. In cats, the virus replicated in the nose and throat and caused inflammatory pathology deeper in the respiratory tract, and airborne transmission did occur between pairs of cats. Dogs appeared not to support viral replication well and had low susceptibility to the virus, and pigs, chickens, and ducks were not susceptible to SARS-CoV-2.
Science, this issue p. 1016; see also p. 942
Abstract
Severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2) causes the infectious disease COVID-19 (coronavirus disease 2019), which was first reported in Wuhan, China, in December 2019. Despite extensive efforts to control the disease, COVID-19 has now spread to more than 100 countries and caused a global pandemic. SARS-CoV-2 is thought to have originated in bats; however, the intermediate animal sources of the virus are unknown. In this study, we investigated the susceptibility of ferrets and animals in close contact with humans to SARS-CoV-2. We found that SARS-CoV-2 replicates poorly in dogs, pigs, chickens, and ducks, but ferrets and cats are permissive to infection. Additionally, cats are susceptible to airborne transmission. Our study provides insights into the animal models for SARS-CoV-2 and animal management for COVID-19 control.
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In summary, we found that ferrets and cats are highly susceptible to SARS-CoV-2; dogs have low susceptibility; and pigs, chickens, and ducks are not susceptible to the virus. Unlike influenza viruses and the other SARS-coronavirus known to infect humans (SARS-CoV-1), which replicate in both the upper and lower respiratory tract of ferrets (20, 22–24, 26, 27), SARS-CoV-2 replicates only in the nasal turbinate, soft palate, and tonsils of ferrets. SARS-CoV-2 may also replicate in the digestive tract, as viral RNA was detected in the rectal swabs of the virus-infected ferrets, but virus was not detected in lung lobes, even after the ferrets were intratracheally inoculated with the virus. It remains unclear whether the virus causes more severe disease in male ferrets than in female ferrets, as has been observed among humans (13, 28).
Several studies have reported that SARS-CoV-2 uses angiotensin-converting enzyme 2 (ACE2) as its receptor to enter cells (3, 29–31). ACE2 is mainly expressed in type II pneumocytes and serous epithelial cells of tracheo-bronchial submucosal glands in ferrets (25). Ferrets and cats differ by only two amino acids in the SARS-CoV-2 spike-contacting regions of ACE2 (table S1); therefore, the underlying mechanism that prevents the replication of SARS-CoV-2 in the lower respiratory tract of ferrets remains to be investigated. The fact that SARS-CoV-2 replicates efficiently in the upper respiratory tract of ferrets makes them a candidate animal model for evaluating the efficacy of antiviral drugs or vaccines against COVID-19.
The cats we used in this study were outbred and were susceptible to SARS-CoV-2, which replicated efficiently and was transmissible to naïve cats. Cats in Wuhan have been reported to be seropositive for SARS-CoV-2 (32). Surveillance for SARS-CoV-2 in cats should be considered as an adjunct to elimination of COVID-19 in humans.
TUESDAY, JUNE 2, 2020
USDA APHIS Confirmation of COVID-19 in Pet Dog in New York
WEDNESDAY, APRIL 22, 2020
APHIS Confirmation of COVID-19 in Two Pet Cats in New York
Coronavirus can survive long exposure to high temperature, a threat to lab staff around world: paper
The new
can survive long exposure to high temperatures, according to an experiment by a team of French scientists.
Professor Remi Charrel and colleagues at the Aix-Marseille University in southern
heated the virus that causes Covid-19 to 60 degrees Celsius (140 Fahrenheit) for an hour and found that some strains were still able to replicate.
The scientists had to bring the temperature to almost boiling point to kill the virus completely, according to their non-peer-reviewed paper released on bioRxiv.org on Saturday. The results have implications for the safety of lab technicians working with the virus.
Coronavirus can survive long exposure to high temperature, a threat to lab staff around world: paper
The new coronavirus can survive long exposure to high temperatures, according to an experiment by a team of French scientists.
Professor Remi Charrel and colleagues at the Aix-Marseille University in southern France heated the virus that causes Covid-19 to 60 degrees Celsius (140 Fahrenheit) for an hour and found that some strains were still able to replicate.
The scientists had to bring the temperature to almost boiling point to kill the virus completely, according to their non-peer-reviewed paper released on bioRxiv.org on Saturday. The results have implications for the safety of lab technicians working with the virus.
TUESDAY, JUNE 30, 2020
TRUMP COVID VIRUS 2020
Terry S. Singeltary Sr.
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