COVID-19 Resource Library
COVID-19 Resource Library

Real Time COVID-19 Coverage and Best Practices

Being a business is challenging enough without a global crisis causing uncertainty about the immediate future. That’s why we’re dedicated to bringing you the most accurate and timely information to help you research the best return-to-work strategy for your unique needs. Curated by our expert medical partners, this resource hub keeps you up to date on relevant coronavirus developments.

Viral shedding can last several weeks

We found virus shedding was up to 6 weeks after onset of symptoms.

Source: CID - 4/19/2020 - profile of SAR-CoV-2 PCR in 56 COVID pts.

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No evidence that ACEis or ARBS affect risk of COVID-19

6272 cases. Use of ACE inhibitors and ARBs was more frequent among patients with COVID-19 than among controls because of their higher prevalence of cardiovascular disease. However, there was no evidence that ACE inhibitors or ARBs affected the risk of COVID-19.

Source: NEJM - 5/1/2020 - RAAS blockers and risk of COVID-19

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Stroke and COVID-19

Retrospective - 5 cases. Incidence of stroke among hospitalized patients with COVID-19 was approximately 5%; the youngest patient in that series was 55 years of age. Moreover, large-vessel stroke was reported in association with the 2004 SARS-CoV-1 outbreak in Singapore.

Source: NEJM - 4/28/2020 - large-vessel stroke in COVID-19 in the young

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Epi on children and COVID-19 from Italy

  • 100 children

  • 21% of the patients were asymptomatic

  • 58% had mild disease

  • 19% had moderate disease

  • 1% had severe disease

  • 1% were in critical condition

  • No deaths were reported. A total of 38% of the patients were admitted to the hospital because of symptoms, irrespective of the severity of disease

  • 21% of the patients were asymptomatic, 58% had mild disease, 19% had moderate disease, 1% had severe disease, and 1% were in critical condition (Table S5). Most of the infants presented with mild disease. Severe and critical cases were diagnosed in patients with coexisting conditions. No deaths were reported. A total of 38% of the patients were admitted to the hospital because of symptoms, irrespective of the severity of disease.

Source: NEJM - 5/1/2020 - Children in Italy with COVID-19

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Rethinking hospital-at-home programs

A 2016 Cochrane review evaluating the effectiveness and cost of hospital care at home found:

  • no difference in 6-month mortality

  • no difference in being transferred or readmitted to a hospital

  • higher satisfaction with health care

  • lower costs

  • In another randomized controlled trial, 3 patients hospitalized at home were less sedentary and also had lower rates of readmission.

Source: JAMA - 5/1/2020 - Hospital-at-home Model

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Cutaneous manifestation of COVID-19

Source: JEADV - 3/16/2020 - 88 patients    

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Remdesivir and COVID-19

  • 237 patients were enrolled

  • Remdesivir use was not associated with a difference in time to clinical improvement (hazard ratio 1·23 [95% CI 0·87–1·75]).

  • Although not statistically significant, patients receiving Remdesivir had a numerically faster time to clinical improvement than those receiving placebo among patients with symptom duration of 10 days or less

  • This study is believed underpowered.

  • There is a study out of the U of Nebraska with Remdesivir demonstrating clinical/symptom improvement of 4 days - waiting on publication.
    --> Remdesivir had a 31% faster time to recovery than those who received placebo (p < 0.001 ) Specifically, the median time to recovery was 11 days for patients treated with Remdesivir compared with 15 days for those who received placebo. Results also suggested a survival benefit, with a mortality rate of 8.0% for the group receiving Remdesivir versus 11.6% for the placebo group (p=0.059).

Source: Lancet - 4/30/2020 - Remdesivir and COVID

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COVID-19 is a thromboembolic disease

  • Prophylactic administration of low-molecular-weight heparin should be initiated, and routine D-dimer testing obtained on admission and serially during hospital stay in all hospitalized patients suspected to have COVID-19, irrespective of risk scores (eg, Padua score).

  • A baseline, non-contrast chest CT should be considered for all hospitalized patients suspected to have COVID-19

  • CT pulmonary angiography should be considered if there is clinical suspicion for PE based on such factors as hemoptysis, unexplained tachycardia, signs/symptoms of DVT, acute deterioration upon moving patient, and with elevated D-dimer level.

  • D-dimer values should aide prognostic stratification, with additional imaging as indicated.

  • If PE is confirmed, therapeutic anticoagulation is indicated.

Source: Radiology - 4/23/2020 - COVID recognized as thromboembolic disease affecting multiple organs

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COVID-19 and Kawasaki disease

  • Increased incidence of atypical Kawasaki in children with COVID-19

  • Reports in Italy have reported 6-fold increase in reported Kawasaki.

Source: Hospital Pediatrics - 4/2020 - COVID-19 and Kawasaki disease

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Commercial COVID-19 antibody testing

Source: Commercial COVID-19 Antibody Testing - Position Statement from IDSA - 4/29/2020

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COVID-19 and airborne transmission

We propose that SARS-CoV-2 may have the potential to be transmitted via aerosols. Our results indicate that room ventilation, open space, sanitization of protective apparel, and proper use and disinfection of toilet areas can effectively limit the concentration of SARS-CoV-2 RNA in aerosols

Source: Nature - 4/28/2020 - Aerodynamic analysis of SARS-CoV-2

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Mutation tracking in SARS-CoV-2

We have developed an analysis pipeline to facilitate real-time mutation tracking in SARS-CoV-2, focusing initially on the Spike (S) protein because it mediates infection of human cells and is the target of most vaccine strategies and antibody-based therapeutics... The mutation Spike D614G is of urgent concern; it began spreading in Europe in early February, and when introduced to new regions it rapidly becomes the dominant form.

Source: bioRxiv - 4/30/2020 - Spike mutation pipeline and increased transmissibility of SARS-CoV-2

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AC and in-hospital survival

In patients who required mechanical ventilation (N=395), in-hospital mortality was 29.1% with a median survival of 21 days for those treated with AC as compared to 62.7% with a median survival of 9 days in patients who did not receive AC (Figure 1B). In a multivariate proportional hazards model, longer duration of AC treatment was associated with a reduced risk of mortality (adjusted HR of 0.86 per day, 95% confidence interval 0.82-0.89, p<0.001).

Source: JACC - 7/7/2020 - Association of Treatment Dose Anticoagulation With In-Hospital Survival Among Hospitalized Patients With COVID-19

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Antibody response report - bioRxiv

  • most convalescent plasmas obtained from individuals who recover from COVID-19 without hospitalization do not contain high levels of neutralizing activity. Nevertheless, rare but recurring RBD-specific antibodies with potent antiviral activity were found in all individuals tested, suggesting that a vaccine designed to elicit such antibodies could be broadly effective

Source: bioRxiv - 5/15/2020 - antibody response to COVID

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Antibody response report - Nature

  • We report acute antibody responses to SARS-CoV-2 in 285 patients with COVID-19. Within 19 days after symptom onset, 100% of patients tested positive for antiviral immunoglobulin-G (IgG). Seroconversion for IgG and IgM occurred simultaneously or sequentially. Both IgG and IgM titers plateaued within 6 days after seroconversion

Source: Nature - 4/29/2020 - Antibody Responses to COVID-19

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Hydroxychloroquine and COVID-19

The risk of intubation or death was not significantly higher or lower among patients who received hydroxychloroquine than among those who did not. Our findings do not support the use of hydroxychloroquine at present, outside randomized clinical trials testing its efficacy.

Source: NEJM - 5/7/2020 - Observational Study of Hydroxychloroquine for COVID-19 in NYC (1376 patients)

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Interpreting diagnostic tests

In most individuals with symptomatic COVID-19 infection, viral RNA in the nasopharyngeal swab as measured by the cycle threshold (Ct) becomes detectable as early as day 1. This positivity starts to decline by week 3. Viral RNA has been detected by RT-PCR even beyond week 6. A “positive” PCR result reflects only the detection of viral RNA and does not necessarily indicate presence of viable virus. The most sensitive and earliest serological marker is total antibodies, levels of which begin to increase from the second week of symptom onset. Although IgM and IgG ELISA have been found to be positive even as early as the fourth day after symptom onset, higher levels occur in the second and third week of illness

Source: JAMA - 5/6/2020 - Interpreting Diagnostic tests for SARS CoV-2

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Triple therapy in COVID-19

127 patients were recruited; prospective, randomized controlled

  • The combination group had a significantly shorter median time from start of study treatment to negative nasopharyngeal swab (7 days [IQR 5–11]) than the control group (12 days [8–15]; hazard ratio 4·37 [95% CI 1·86–10·24], p=0·0010).

  • Adverse events included self-limited nausea and diarrhoea with no difference between the two groups.

  • Early triple antiviral therapy was safe and superior to lopinavir–ritonavir alone in alleviating symptoms and shortening the duration of viral shedding and hospital stay in patients with mild to moderate COVID-19

Source: Lancet - 5/8/2020 - triple therapy with Interferon, lopinavir-ritonavir and ribavirin - 127 pts

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Interlukin-1 blockers and COVID-19

29 patients received high-dose intravenous anakinra, non-invasive ventilation, and standard treatment.

  • 16 patients received non-invasive ventilation and standard treatment only and comprised the comparison group for this study.

  • At 21 days, treatment with high-dose anakinra was associated with reductions in serum C-reactive protein and progressive improvements in respiratory function in 21 (72%) of 29 patients; five (17%) patients were on mechanical ventilation and three (10%) died.

  • At 21 days, survival was 90% in the high-dose anakinra group and 56% in the standard treatment group (p=0·009).

  • In this retrospective cohort study of patients with COVID-19 and ARDS managed with non-invasive ventilation outside of the ICU, treatment with high-dose anakinra was safe and associated with clinical improvement in 72% of patients. Confirmation of efficacy will require controlled trials

Source: Lancet -5/5/2020 - Interlukin-1 blockers and COVID-19

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SARS-CoV-2 in pregnant women

  • 782 patients presenting for childbirth were screened

  • 30 of 770 (3.9%) tested positive for SARS-CoV-2

  • 22 of the 30 who tested positive for SARS-CoV-2 (73.3%) were asymptomatic

Source: JAMA - 5/26/202 - Prevalence of SARS-CoV-2 in pregnant women in Connecticut

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Utility of retesting for COVID-19 diagnosis

Our data suggests that short interval testing is low yield. Assuming that specimen collection is appropriate, the presence or absence of virus in the nasopharynx or other sites is not expected to change dramatically within 24 hours. Our patient with discordant results in the course of symptomatic illness had testing performed at an interval of 6 days, suggesting that changes in viral shedding may have occurred over that time period.

Source: ICHE - 5/11 - Utility of retesting for COVID-19 diagnosis - 70 patients tested

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Bacterial/fungal pulmonary co-infection

  • 1007 abstracts reviewed

  • Despite frequent prescription of broad-spectrum empirical antimicrobials in patients with coronavirus associated respiratory infections, there is a paucity of data to support the association with respiratory bacterial/fungal co-infection

Source: CID - 5/2/2020 - bacterial and fungal co-infection and COVID

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Experimental data on aerosolization

  • Speech droplets generated by asymptomatic carriers of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are increasingly considered to be a likely mode of disease transmission. Highly sensitive laser light scattering observations have revealed that loud speech can emit thousands of oral fluid droplets per second. In a closed, stagnant air environment, they disappear from the window of view with time constants in the range of 8 to 14 min, which corresponds to droplet nuclei of ca. 4 μm diameter, or 12- to 21-μm droplets prior to dehydration. These observations confirm that there is a substantial probability that normal speaking causes airborne virus transmission in confined environments

  • Our laser light scattering method not only provides real-time visual evidence for speech droplet emission, but also assesses their airborne lifetime. This direct visualization demonstrates how normal speech generates airborne droplets that can remain suspended for tens of minutes or longer and are eminently capable of transmitting disease in confined spaces 

Source: PNAS - 5/13/2020 - Airborne lifetime of speech droplets

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More Kawasaki reported in children

  • 30-fold increased incidence of Kawasaki-like disease in Italy.  Children diagnosed after the SARS-CoV-2 epidemic began showed evidence of immune response to the virus, were older, had a higher rate of cardiac involvement, and features of MAS (Macrophage Activation Syndrome). The SARS-CoV-2 epidemic was associated with high incidence of a severe form of Kawasaki disease. A similar outbreak of Kawasaki-like disease is expected in countries involved in the SARS-CoV-2 epidemic

Source: Lancet - 5/13/2020 - Kawasaki and children

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Results of convalescent plasma use

  • primary study outcome was safety

  • secondary outcome was clinical status at day 14 post-transfusion

  • At baseline, all patients were receiving supportive care, including anti-inflammatory and anti-viral treatments, and all patients were on oxygen support.

  • At day 7 post-transfusion with convalescent plasma, nine patients had at least a 1-point improvement in clinical scale, and seven of those were discharged.

  • day 14 post-transfusion, 19 (76%) patients had at least a 1-point improvement in clinical status and 11 were discharged.

  • No adverse events as a result of plasma transfusion were observed. The whole genome sequencing data did not identify a strain genotype-disease severity correlation

Source: MedRxiv - 5/13/2020 - results of Convalescent plasma in Houston - 25 patients

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No effects of BCG vaccination on COVID-19

  • There was no statistically significant difference in the proportion of positive test results in the BCG-vaccinated group (361 [11.7%]) vs the unvaccinated group (299 [10.4%]; 

  • In this cohort of Israeli adults aged 35 to 41 years, BCG vaccination in childhood was associated with a similar rate of positive test results for SARS-CoV-2 compared with no vaccination

Source: JAMA - 5/13/2020 - SARS-CoV-2 rates in BCG -vaccinated and unvaccinated individuals

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Resumption of exercise after COVID-19

  • Nice algorithm for symptomatic and asymptomatic COVID and resumption of exercise and sports related activity. 

Source: JAMA - 5/13/2020 - resumption of exercise and sports after COVID

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GI symptom presentation in COVID-19

  • The pooled prevalence of digestive symptoms was 15% with nausea or vomiting, diarrhea, and loss of appetite being the three most common symptoms.

  • The pooled prevalence of abnormal liver functions was 19%

  • Subgroup analysis showed patients with severe COVID-19 had higher rates of gastrointestinal symptoms (odds ratio [OR] 1·60 [95% CI 1·09–2·36]; p=0·0020; and liver injury (2·20 [1·60–3·02]; p<0·00001; compared with those with non-severe disease. 

  • Our study showed that digestive symptoms and liver injury are not uncommon in patients with COVID-19

Source: LANCET - 5/12/2020 - manifestations and prognosis of GI and liver involvement in COVID - meta-analysis

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Deaths in HCW from Italy report

  • Since the first case of the outbreak on 21 February, the number of healthcare worker deaths has risen dramatically.

  • On April 17 the latest estimate of medical doctor deaths reached 119 which is 57.8% of total healthcare worker deaths; followed by nurses 16.5% , nurse aides 8.3% and dentists 5.8%

  • China, where the epidemic began in  December, had fewer General practitioners seem to be the worst hit amongst all medical specialties, registering 32% deaths.  This could reflect their presence in the first line of defense for anyone presenting with the first symptoms

  • The sheer intensity of the COVID-19 outbreak in Italy, the recruitment of elderly retired doctors and shortages of PPE, particularly in non-hospital care, might be among relevant factors contributing to the elevated number of fatalities among healthcare workers in this country 

Source: SHEA - 5/15/2020 - Deaths in HCW from COVID in Italy

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COVID-19 and Vitamin-D

  • The most commonly affected countries with severe vitamin D deficiency are from the subtropical (Saudi Arabia; 46%, Qatar; 46%, Iran; 33.4%, Chile; 26.4%) and midlatitude (France; 27.3%, Portugal; 21.2% and Austria; 19.3%) regions. Severe vitamin D deficiency was found to be nearly 0% in some high latitude countries (e.g. Norway, Finland, Sweden, Denmark and Netherlands).

  • Accordingly, we would like to call attention to the possible association between severe vitamin D deficiency and mortality pertaining to COVID-19. Given its rare side effects and relatively wide safety, prophylactic vitamin D supplementation and/or food fortification might reasonably serve as a very convenient adjuvant therapy for these two worldwide public health problems alike

Source: SHEA - 5/12/2020 - COVID-19 and vitamin D

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